Orthopaedic Journal of MP Chapter

Publisher: Madhya Pradesh Orthopaedic Association www.mpioa.com
E-ISSN:2582-7243, P-ISSN:2320-6993
2021 Volume 27 Number 2 Jul-Dec

Evaluation of percutaneous fixation of intra articular fractures of calcaneum using Essex Lopresti manoeuvre

Mantri D1, Jain S2, Kothari N3*

1 D Mantri, Department of Orthopaedics, Mahatma Gandhi Memorial Medical College, Indore, Madhya Pradesh, India.

2 S Jain, Department of Orthopaedics, Mahatma Gandhi Memorial Medical College, Indore, Madhya Pradesh, India.

3* Nilesh Kothari, Resident, Department of Orthopaedics, Mahatma Gandhi Memorial Medical College, Indore, Madhya Pradesh, India.

Background: Debate continues regarding the ideal management of calcaneal fractures, between open reduction and internal fixation and closed methods. Open plating has failed to prove its superiority over closed methods owing to poor soft tissue coverage, severe soft tissue swelling, lack of availability of sturdy implants and complications associated with plating. Hence we evaluated the outcome of percutaneous fixation of tongue type intra-articular fracture of calcaneum by Essex Loprestimanoeuvre.

Material and methods: 30 tongue type intra-articular fractures of calcaneum in 23 patients operated by Essex Loprestimanoeuvre by closed reduction and percutaneous pin fixation were assessed functionally by Maryland foot score and radiologically by Bohler’s angle and Gissane’s angle.

Results: 30 calcaneal fractures with mean age 31.6 years and mean follow up of 8.3 months were included in the study. The mean pre-operative Bohler’s angle improved from 8.300 ± 3.84, to 24.470 ± 8.31 immediate postoperatively and to 24.330 ± 8.46 at final follow up of 6 months, respectively. The mean pre-operative Gissane’s angle improved from 134.130 ± 7.03, to 123.150 ± 8.79 immediate postoperatively and to 123.550 ± 8.82 at final follow up of 6 months, respectively. Mean union time was 9 weeks. The mean Maryland Foot Score was 83.43 ± 7.53 (range 61 to 92) and 86 % cases had excellent to good results.

Conclusion: Essex-Lopresti’s method for treatment of tongue-type fractures of calcaneum is easy, cost effective, day care procedure provides stable fixation, early mobilization and excellent results, with low complication rates.

Keywords: Tongue type calcaneal fracture, Bohler’s Angle, Gissane’s angle, Maryland Foot Score

Corresponding Author How to Cite this Article To Browse
Nilesh Kothari, Resident, Department of Orthopaedics, Mahatma Gandhi Memorial Medical College, Indore, Madhya Pradesh, India.
Email:
Mantri D, Jain S, Kothari N, Evaluation of percutaneous fixation of intra articular fractures of calcaneum using Essex Lopresti manoeuvre. ojmpc. 2021;27(2):85-89.
Available From
https://ojmpc.com/index.php/ojmpc/article/view/140
Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2021-12-07 2021-12-13 2021-12-19 2021-12-25 2021-12-31
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Authors state no conflict of interest. Non Funded. The conducted research is not related to either human or animals use. 11.23 All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

© 2021by Mantri D, Jain S, Kothari Nand Published by Madhya Pradesh Orthopaedic Association. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by-nc/4.0/ unported [CC BY NC 4.0].

Introduction

Calcaneal fractures are the most common fractures of the foot and represent 1 to 2% of all fractures. Among these fractures, more than 75% fractures are intra-articular fractures, which are frequently associated with prolonged disability if not treated properly [1,2].

These fractures have a track record of being difficult to treat owing to position and nature of bone i.e. being subcutaneous, cancellous, weight bearing small bone and also due to peculiar fracture patterns i.e. severely communited, depressed and intra-articularfragments [3].

Thus treatment of these calcaneal fractures require re–apposition of multiple fracture fragments and restoration of the subtalar joint anatomy, which is the interface between the calcaneus and talus and is the primary load bearing joint of the foot, along with providing respect to the thin subcutaneous tissuecovering overlying calcaneum [4].

Various modalities for the treatment of these fractures are plaster, plaster pins, external fixation, internal fixation by screws and plate. All these techniques have certain steps in common which include dis-impaction of the fragments, reduction of the displaced fragments along with joint restoration either manually or percutaneously and retaining the reduction alignment.

Among the popularly used techniques, open methods have the significant issue of repeated surgeries, associated soft tissue trauma and high rate of wound healing problems while among the closed methods K-wires and pins have the advantage of easy implant removal without need of repeat surgery [5,6].

Hence we evaluated the outcome of close reduction and K-wire or pin fixation in30 tongue type intra-articular calcaneal fractures by Essex Loprestimanoeuver.

Material and methods

This study was conducted on 30 cases with tongue type intra-articular fractures of calcaneum treated by Essex Lopresti method at our institute. All patients of closed or grade 1 open tongue type intra-articular fractures of calcaneum, between 18 and 60 years of age, presenting within 2 weeks of injury were included in the study.

All the patients with neurovascular injury, pathological fracture or other associated injuries were excluded from the study. The study was approved by the institutional review board and ethical committee of the institute and well explained written consent was obtained from all the participants.All patients were primarily stabilized with intravenous fluids and analgesics.

Standard axial and lateral calcaneal radiographs were taken and following this, abelow knee slab was applied, limb was elevated and ice fomentation was done, primarily to reduce the swelling. Analgesics and anti-inflammatory medications were given.Patients were treated by percutaneous fixation of k wire / pin with Essex Loprestimanoeuvre[7,8].

All patients were operated, under the C-arm following all aseptic precautions in spinal anaesthesia in lateral position with affected limb above. Primarily aSteinmannpin or K-wire (3.0mm, 3.5 mm or 4.0 mm diameter with 9”length)was inserted from posterior calcaneal tuberosity and advanced till the fracture line keeping it just proximally to fracture line, without crossing the fracture (Figure 1a). Reduction of the tongue type intra-articular calcaneum fracture was achieved by plantar flexion of the forefoot and down warding pulling of the pin / k wire from outside towards the planter surface to dis-impact the fragment by joy stickingto elevate the depressed tongue type fracture (Figure 1b).

Intra-operative, lateral and axial C-arm views were taken to confirm reduction and restoration of Bohler’s angle within normal range of 200-400. Once reduction was achieved, and depressed fragment was elevated, a second Steinmannpin was inserted from superior external side of calcaneal tuberosity towards tarsal bone, holding the reduction, passing across the fracture line and fixing both the fragments(Figure 1c). Following this, a third pin or K- wire was inserted inferior to the first Steinmann pin for additional fracture fragment stabilization as well as fixation. Finally, the first joystickingpin / k wire was removed(Figure 1d) and another k-wire was inserted from posterior of the calcaneum tuberosity, traversing the fracture fragment and reaching towards the tarsal bones(Figure 1 ef).

After confirming the reduction andpin placement in C arm, finally pin tract dressing was done and below knee cast was applied after shortening the pins with the help of Harrington rod cutter. The limb was kept elevated and active toe movementswere started from second postoperative day. Oral analgesics and antibiotics were given for 5days. Cast care was explained to the patient as well as relatives. Patients were followed up regularly at 2 weeks each. Plaster and K-wires/pins were removed at 8 weeks and ankle range of motion started andfull weight was started at 12 weeks.Functional outcomeassessment was done by Maryland foot score and radiological outcome assessment was done by comparing restoration of Bohler’s angle and Gissane’sangle, postoperatively [9,10].

Results

23 patientswith 30 calcaneal fractures treated with Essex Loprestimanoeuvre were included in the study.


The mean age in our series was 31.6 years (range 18 to 54 years). 19 patients were male and 4 were female. 11 patients had fracture of left side, 5 had right side and 7 sustained bilateral fractures. The most common mechanism of injury was fall from height seen in 17 patients and 6 had road traffic accident. The mean follow up period was 8.3 months (range 6 to 12 months).

Figure 1:Intra-operative lateral fluoroscopic views (a to f) showing steps of Essex Loprestimanoeuvre – Insertion of first steinmann pin from posterior calcaneal tuberosity (a), achieving reduction by plantar flexion of forefoot and downward joysticking of the first pin (b), insertion of second and third steinmann pin from superior side of calcaneal tuberosity towards tarsal bone for holding the reduction (c & d), removal of first joysticking pin (e) and finally insertion of another pin to hold reduction (f).
ojmpc_140_01.JPG

Figure 2: Lateral (a) and axial (b) view of heel of 20-year-old male showing tongue type calcaneal fracture with preoperative Bohler’s angle of 10.60&Gissane’s angle of 133.70. Immediate postoperative lateral (c) and axial (d) views after Essex lopresti manoeuvre showing improved Bohler’s&Gissane’s angle to 26.80& 127.80 respectively. Final 6 months post-operatively lateral (e) & axial (f) views showing Bohler’s and Gissane’s angle of 27.20 and 1280 and MFS as 90.
ojmpc_140_02.JPG

The mean operative time was 12.86 minutes (range 8 to 20 minutes). The mean pre-operative Bohler’s angle improved from 8.300±3.84, to 24.470 ± 8.31 immediate postoperatively and to 24.330±8.46 at final follow up of6 months, respectively.

The mean pre-operative Gissane’s angle improved from 134.130±7.03, to 123.150 ±8.79 immediate postoperatively and to 123.550 ± 8.82 at final follow up of 6 months, respectively (fig 2). Mean union time was 9 weeks (range 8 to 12 weeks). The mean Maryland Foot Score was 83.43 ± 7.53 (range 61 to 92). In 6 (20.0%) patients the Maryland Foot Score was excellent, in 20 (66.7%) patients it was good and in 4 (13.3%) patients it was fair.

Complications associated with the procedure were implant loosening in 1 patient (3.3%) and subtalar arthritis in 2 patients (6.7%). None of the cases had infection or wound healing problems associated with the procedure.

Discussion

Calcaneal fractures are the most common foot fractures, accounting for approximately 2% of all fractures and 75% of all fractures of foot, of which 10% are bilateral, 10% have associated injuries and 75% are intra-articular fractures [1-5]. Debate continues regarding the ideal management of calcaneal fractures, between open reduction and internal fixation and closed methods. Open plating invariably leads to inconsistent results and had failed to prove its superiority over closed methods owing to poor soft tissue coverage, severe soft tissue swelling associated with the fracture, lack of availability of sturdy implants, complications associated with plating and comparatively poor functional outcomes [5,6].

30 tongue type intra-articular calcaneal fractures in 23 patients with mean age 31.6 years treated by Essex Loprestimanoeuvre were included in the study. In our study, mean Maryland Foot score was 83.43 ± 7.53 with 86 % patients having excellent to good results and rest showing fair results and none of the patients had poor results. In two studies by Tornetta et al in 1998 and 2000, who had also treated these fractures by percutaneous fixation showed 85% cases having excellent to good results with15% having fair results and no patient having poor result as per Maryland Foot Score [11,12].

The mean MFS in study by Pillai et al and Scheppers et al was 77 and 79 respectively which was slightly less than that of our study, but the study by Parikh et al had mean score of 85 which was almost same as ours [5,13,14]. In all these studies, the number of patients with excellent to good results were comparable to our study with more than 80 % patients having excellent to good results.


The mean correction achieved in Bohler’s angle in our study was 16.270, which was comparable to other studies of Pillai et al, Scheppers et al, Parikh et al and Arastu et al who achieved correction ranging from 150 to 200 [5, 13-15].Pillai et al compared outcome of modified Essex Loprestimethod using Bohler’sstrip for reduction in tongue and depressed type intra-articular fractures and found that overall functional score was significantly better in tongue type group [5].

Various modifications ofEssex Loprestimethod to achieve accurate reduction of articular surface have been used and described by various authors like use of Bohler strip by Pillai et al, use of distractor by Scheppers et al, fixation of calcaneum fracture by screws by Parikh et al or use of elevator or laminar spreader to elevate the depressed fragment by Arastu et al [5,13-15].

All these methods have demonstrated that Essex Loprestimethod is an excellent method for reduction of tongue type fractures to achieve good restoration of hind foot morphology and provides excellent results.

Percutaneous fixation of calcaneal fracture by Essex Lopresti method has very short learning curve, does not demand much expertise, can be easily perfected, has very short surgical time and the technique can be safely performed even in presence of extensive soft tissue swelling i.e. even immediately following injury reducing the duration of hospitalization and burden on to the patient as well as on the healthcare system.

Conclusion

Essex-Lopresti’s method of closed reduction and percutaneous pin fixation is a good treatment option for tongue-type intra-articular fractures ofcalcaneum which is easy to perform, requires average surgical skills, is cost effective day care procedure providing stable fixation, early mobilization and excellent results, with lower complications.

References

1. Buckley RE, Tough S. Displaced intra-articular calcaneal fractures. J Am AcadOrthop Surg. 2004 May-Jun;12(3):172-8. [Crossref][PubMed][Google Scholar]

2. Potter MQ, Nunley JA. Long-term functional outcomes after operative treatment for intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2009 Aug;91(8):1854-60. [Crossref][PubMed][Google Scholar]

3. Khetan VV, Patel I, Modi DR, Panchal N, Bhavsar N, Joshi A. Functional outcome of calcaneal fractures treated by various methods. Niger J Orthop Trauma 2019. 18:44-7. [Crossref][PubMed][Google Scholar]

4. Zwipp H, Rammelt S, Barthel S. Calcaneal fractures-open reduction and internal fixation (ORIF). Injury. 2004 Sep;35;Suppl 2:SB46-54. [Crossref][PubMed][Google Scholar]

5. Pillai A, Basappa P, Ehrendorfer S. Modified Essex-Lopresti / Westheus reduction for displaced intra-articular fractures of the calcaneus. Description of surgical technique and early outcomes. ActaOrthop Belg. 2007 Feb;73(1):83-7 [Crossref][PubMed][Google Scholar]

6. Tolani A, Desai Y. Management of ComminutedCalcaneum Fractures by Closed Reduction and Percutaneous Fixation-A Case Study. J Orthop Rehab 2015 Jult-Sep;1(2):20-24. . [Crossref][PubMed][Google Scholar]

7. Essex-LoprestiP. Results of Reduction in Fractures of the Calcaneum. J. Bone Joint Surg. 1951;33:284 [Crossref][PubMed][Google Scholar]

8. Essex-LoprestiP. The Mechanism, ReductionTechnique and Results in Fractures of the OsCalcis. Br J Surg. 1952;39(157):395–419. [Crossref][PubMed][Google Scholar]

9. Bohler L. Diagnosis, Pathology and Treatment of fractures of the Oscalcis. J Bone Joint Surg. 1931;13:75-89. [Crossref][PubMed][Google Scholar]

10. Gissane W. Discussion on “Fractures of the OsCalcis”. Proceedings of the British Orthopaedic Association. J. Bone Joint Surg(Am).1947:Jan;(29):254–5 [Crossref][PubMed][Google Scholar]

11. Tornetta P 3rd. The Essex-Lopresti reduction for calcaneal fractures revisited. J Orthop Trauma. 1998 Sep-Oct;12(7):469-73. [Crossref][PubMed][Google Scholar]

12. Tornetta P 3rd. Percutaneous treatment of calcaneal fractures. ClinOrthopRelat Res. 2000 Jun;(375):91-6. [Crossref][PubMed][Google Scholar]

13. Schepers T, Schipper IB, Vogels LM, Ginai AZ, Mulder PG, Heetveld MJ, Patka P. Percutaneous treatment of displaced intra-articular calcaneal fractures. J Orthop Sci. 2007 Jan;12(1):22-7. [Crossref][PubMed][Google Scholar]

14. Parikh KN, Moradiya N, Shah S, Khodifad A. Evaluation of results of minimally invasive per cutaneous surgeries in management of calcaneal fractures. Int J Res Orthop 2019;5:81-6. . [Crossref][PubMed][Google Scholar]

15. Arastu M, Sheehan B, Buckley R. Minimally invasive reduction and fixation of displaced calcaneal fractures: surgical technique and radiographic analysis. IntOrthop. 2014 Mar;38(3):539-45. [Crossref][PubMed][Google Scholar]


16. Tolani A, Desai Y. Management of ComminutedCalcaneum Fractures by Closed Reduction and Percutaneous Fixation-A Case Study. JOrthop Rehab. 2015; 1(2): 20-4. [Crossref][PubMed][Google Scholar]

Disclaimer / Publisher's Note

The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of Journals and/or the editor(s). Journals and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.