الفهرس 
Introduction and aim of the workOnly 14 pages are availabe for public view
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Abstract
The current study, a randomized controlled study, was conducted on a total of 34 feet (28 patients) with Sanders type II or III DIACFs (6 patients had bilateral fractures and 22 patients had unilateral fracture), at orthopaedics and traumatology department of Sohag university hospital, between June 2020 and February 2022. The patients of the study were randomly divided between two groups; cannulated screws and K-wires groups, each group was composed of 11 unilateral and 3 bilateral fractures. The method of randomization done was the stratified randomization.
The purpose of this current prospective study was to compare the functional and radiographic outcomes of 2 minimally invasive techniques of closed reduction and percutaneous fixation in treatment of Sanders type II and III DIACFs using cannulated screws or K-wires without use of bone grafts.
The mean ages of the included patients were 34.8 ± 9.3 (range, 22-55) years and 36.6 ± 12 (range, 23-57) years for the cannulated screws group and the K-wires group, respectively.
The vast majority of patients were males (78.6%). This male predominance was more evident among cannulated screws group (13 males &1 female) compared to the K-wires group (9 males & 5 females).
Half of patients of had isolated right sided fractures, with only one fifth had bilateral fractures. The involvement of the right side was more common in the cannulated screws group (57%) than in the K-wires group (43%), with equal bilateral fractures of both groups.
The mechanism of injury in the vast majority of the patients, was falling from height, seen in over 82% of the patients; with only 5 cases had other causes (road traffic accident; 3 patients and falling down stairs; 2 patients).
CT scan was used to delineate the fracture pattern and for fracture classification. More than 70% of fractures were type III according to Sanders classification, and about 30% of fractures were type II. According to Essex-Lopersti classification, the majority of cases had joint depression type (73.5%) and the remaining had tongue type (26.5%). The difference between the two groups was non-significant.
Around two thirds of the patients were non-smokers, with slight rise of smokers among cannulated screws group.
The mean time lapsed from trauma to surgery was 6 ± 4.5 (range, 1-14) days, and 5 ± 4.4 (range, 1-14) days for the cannulated screws group and the K-wires group, respectively. The mean hospital stay was 1.6 ± 0.5 (range, 1-2) days in the cannulated screws group, and 1.7 ± 0.6 (range, 1-3) days in the K-wires group.
The mean operative time was significantly shorter among K-wires group 42 (range, 35-50) minutes compared to cannulated screws group 57 (range, 45-65) minutes.
The vast majority of patients had isolated DIACFs. Only 2 patients (14.3%) in cannulated screws group, and 6 patients (42.9%) in K-wires group had associated injuries.
The mean follow up period of patients was 12.4 ± 3.7 (range, 8-18) months in the cannulated screws group, and 12.1 ± 3.9 (range, 8-19) months in the K-wires group.
The mean AOFAS ankle-hindfoot score at the final follow up was significantly higher among the cannulated screws group 85.88 ± 8.34 (range, 70-100) points compared to the K-wires group 75.82 ± 9.73 (range, 60−90) points.
The mean final follow-up VAS for pain was 1 ± 0.83 (range, 0-3) in the cannulated screws group, and 1.7 ± 0.85 (range, 1-3) in the K-wires group.
The mean subtalar ROM (inversion and eversion) was significantly higher among cannulated screws group 25 ± 5.3 (range, 15-35) compared to K-wires group group 21.2 ± 5.2 (range, 15-30) degrees
The mean full weight-bearing time was significantly longer among the K-wires group 14.4 ± 1.8 (range, 10-16) weeks compared to cannulated screws group12 ± 1 (range,10-14) weeks. The mean time needed for patients to return to their works was significantly longer among K-wires group 5.4 ± 1 (range,3-7) months compared to cannulated screws group 4.3 ± 0.8 (range, 3-6) months.
The range of number of screws used in cannulated screws group was 2-4 screws; and the range of number of K-wires used in K-wires group was 2-6 K-wires.
The mean time of radiographic evidence of solid union was 8.9 ± 1.6 (range, 6-12) weeks in the cannulated screws group and 10.1 ± 1.5 (range, 8-12) weeks in the K-wires group.
Radiographic evaluation included measurement of three calcaneal angles; angle of Gissane, Böhler’s angle and posterior facet inclination angle and three calcaneal distances (in mm) which are; height, length and width of the calcaneus. The post-operative and the final follow up measurements of the angle of Gissane were lower among the K-wires group compared to the cannulated screws group. The pre-operative, post-operative and final follow up measurements of the calcaneal height, length, and width were lower among the K-wires group compared to the cannulated screws group except for; both the post-operative calcaneal length and the final follow up calcaneal width which showed no significant differences between the two groups.
Cannulated screws group showed significant improvement of the post-operative and final follow up measurements of all radiographic parameters compared to the pre-operative measurements with the exception of the measurements of the angle of Gissane and pre-operative versus final follow up measurement of the calcaneal width.
K-wires group showed significant improvement of the post-operative and final follow up measurements of all radiographic parameters compared to the pre-operative measurements with the exception of the measurements of; pre-operative versus post-operative measurements of the angle of Gissane, post-operative versus final follow up posterior facet inclination angle, post-operative versus final follow up calcaneal length and pre-operative versus post-operative calcaneal width.
Subtalar joint arthritis was evaluated according to Paley and Hall grading system (PGS) as it is reliable, less complex, and easy for everyday clinical purposes. Significant subtalar arthritis (grade 2) was encountered in (11.8%) of feet, and there were no cases of grade 3 arthritis.
There were no incidences of serious complications like the incision infection, nonunion of bones, or osteomyelitis; however, minor complications had occurred. In k-wires group, 3 feet (17.65%) had superficial pin track infections which were treated by dressings and antibiotics. In cannulated screws group, one foot (5.9%) developed peroneal subluxation and tendinitis which were managed conservatively, and one foot (5.9%) developed prominent screw which was managed by removal after solid union. No patient in the current study developed deep infections.
No patient needed further surgery until the last follow-up except for one case screw removal.
Factors associated with better functional outcomes were restoration of the final Böhler’s angle, the final posterior facet inclination angle, and the final calcaneal length.
The only factor associated with worse functional outcomes was development of subtalar joint arthritis.
The current study had some limitations, including the relatively low number of patients, the relatively short follow-up period, and we did not measure the radiation exposure, as a minimally invasive and percutaneous technique carries the risk of increased exposure to radiation. However, this study had advantages of being prospective randomized comparative trial, and provided an emphasis on the effectiveness of minimally invasive procedures for the management of DIACFs in achieving excellent functional and radiographic outcomes with low infection rates.
Conclusion
Both techniques avoided most of the complications associated with ORIF with very lower rate of post-operative wound complications, and shorter hospital stay.
Cannulated screws had the ability of final follow up maintainance of correction that was obtained post-operatively more than K-wires.
Patients in cannulated screws group had better functional and radiographic outcomes, lower rate of subtalar joint arthritis, and high patient satisfaction than patients in K-wires group.
The use of K-wires for fixation has the advantage of reduced operative time than cannulated screws, and easy removal of the K-wires as outpatient procedure.
Proper selection of patients, proper preoperative planning, strong knowledge of the principles of MIS, and strict careful application of both techniques are important for obtaining better functional outcomes and avoiding complications.
A steep learning curve is required for both techniques.
Further studies on MIS techniques of fixation of DIACFs should be conducted with higher number of patients, and longer follow-up period.