| The surgical treatment of displaced intra-articular calcaneal fractures requires a certain learning curve and still needs to maintain a certain degree of proficiency after reaching a certain cumulative amount,so as to achieve the best unity in terms of safety and effectiveness and improve the treatment level of such fractures.Some infection will occur after open reduction and internal fixation of intra-articular calcaneal fractures,especially deep infection of the surgical site,which significantly affects the surgical effect,and even can be disabling and teratogenic,bringing serious adverse effects.Previous studies have demonstrated that multiple factors are associated with the risk of surgical site infections following orthopaedic surgery,and annual volume of surgery by orthopaedic surgeons has a certain associative effect,and because data on this factor are variable,understanding the relationship between this factor and infection will have a key impact on patient treatment tendencies as well as physician training model exploration.However,so far,there is no study on the relationship between the amount of surgery performed by doctors and deep surgical site infection after displaced calcaneal fractures,so the primary purpose of our study is to determine the risk factors affecting deep surgical site infection and focus on exploring the relationship between the amount of surgery performed by doctors and deep infection.Closed reduction is the premise of minimally invasive surgery,and accurate placement can maximize the safety of surgery,reduce surgical trauma and operation time.Therefore,one focus of internal fixation research is to meet the anatomical shape of the calcaneus itself;in addition,because the talus loading process is the most important bony structure for internal fixation of calcaneal fractures,it is of great significance to maintain the stability of fixation and is the preferred site for screw placement,so understanding the anatomical shape of the talus loading process is particularly critical.In the past,there were few studies on calcaneal morphological measurement in Chinese,and there was a lack of comparative studies on calcaneal morphological parameters in different age groups;the measurement method based on X-ray and human specimens easily brought about image overlap,manual measurement error and insufficient number of cases.Therefore,this study intends to reconstruct the calcaneal model by Mimics technique according to the individual calcaneal CT imaging data,observe and measure the morphological parameters of the calcaneus on this basis,explore the general rule of calcaneal morphological changes in Chinese people of different genders and ages,and provide reference and data support for the selection and design of new fixation devices and surgical options.Displaced intra-articular calcaneal fractures are absolute indications for surgery,and how to reduce soft tissue complications after fracture surgery is still a major clinical challenge.Compared with traditional open reduction and internal fixation,minimally invasive surgery has been paid more and more attention in the treatment of displaced calcaneal fractures,and is more and more widely used in clinical practice.This is the mainstream trend of minimally invasive and precise surgery of the foot and ankle,and is also the ultimate goal pursued by surgeons.Our team is committed to the minimally invasive and precise treatment of calcaneal fractures,developed the calcaneal selfpositioning navigation plate,the clinical application was initially successful,the effect is significant,significantly reduced the operation time and surgical trauma,the surgical site infection rate decreased significantly,incision edge necrosis and other problems have been effectively solved;this study intends to carry out a clinical study,with the classic lateral calcaneal extended approach open reduction calcaneal anatomical version internal fixation as the reference group,to explore the closed reduction,lateral calcaneal longitudinal small incision approach,calcaneal self-positioning navigation plate internal fixation comparison results,to expand the clinical application to provide data support.Part 1 Deep surgical site infection after open reduction and internal fixation of displaced intra-articular calcaneal fractures: independent risk factors and the impact of surgeon volume on infectionObjective: Surgical treatment of displaced intra-articular calcaneal fractures requires a certain learning curve and still needs to maintain a certain degree of proficiency after achieving a certain cumulative amount,so as to achieve the best unity in terms of safety and effectiveness and improve the treatment level of such fractures.Infection events will occur after open reduction and internal fixation of intra-articular calcaneal fractures,especially deep surgical site infection(DSSI),which significantly affects the surgical effect,and even can be disabling and teratogenic,bringing serious adverse effects.Previous studies have demonstrated that multiple factors are associated with the risk of surgical site infections following orthopaedic surgery,and annual volume of surgery by orthopaedic surgeons has a certain associative effect,and because data on this factor are variable,understanding the relationship between this factor and infection will have a key impact on patient treatment tendencies as well as physician training model exploration.However,so far,there has been no study on the relationship between the amount of surgery performed by doctors and deep infection at the surgical site after displaced calcaneal fractures,so this study was conducted to determine the risk factors affecting deep infection and focus on exploring the relationship between the amount of surgery performed by doctors and deep infection.Methods: This study was a retrospective analysis of prospectively collected case data from the Surgical Site Infection in Orthopaedic Surgery(SSIOS)database of all adult patients with closed displaced intra-articular calcaneal fractures treated with open reduction and internal fixation from January 2016 to December 2019 in the Third Hospital of Hebei Medical University,and data were obtained by searching the inpatient electronic medical record system.Outcome measure was DSSI within one year after operation,no infection as the control group,excluding patients with superficial infection.The amount of surgery performed by an orthopedic surgeon was defined as the number of calcaneal fractures surgically treated by this physician within the year before this surgery,and according to the receiver operating curve(ROC),the occurrence of deep infection was used as the dependent variable,the amount of surgery performed by the orthopedic surgeon was used as the independent variable,and the optimal cut-off value of the amount of surgery was determined when the Youden index(YI;= sensitivity+specificity-1)was the largest,and its predictive ability was assessed with the area under the curve(AUC),dichotomized by the optimal adjacent value,and the physician was divided into high and low surgical volume,corresponding to patients who were in the high and low surgical volume groups,respectively.Multivariate logistic regression models were constructed to identify independent risk factors for deep surgical site infection,especially the effect of surgical volume,using deep infection as the dependent variable and surgical volume classification,multiple confounders,or covariates as independent variables.This multivariate analysis was repeated and multiple sensitivity analyses were performed to assess the robustness of the results.Results: A total of 1508 patients were initially included in the study,and883 patients were finally included in the analysis after exclusion criteria,of whom 19 developed deep surgical site infection,with an incidence of 2.2%.ROC curves identified an optimal cutoff of 6 for surgeon volume and 6.5%(10/155)for low volume(<6/year)compared with 5.5 times(1.2%,9/728;P<0.001)for high volume(≥6/year).Univariate analysis showed that there were statistically significant differences in residence(urban,40.0% vs 30.9%,P=0.005),diabetes(7.7% vs 4.0%,P=0.043),surgical incision level II vs I grade(6.5% vs 1.2%,P=0.002)and bone grafting(3.9% vs 9.3%,P=0.026)between the high and low surgical volume groups.In addition,patients in the lowvolume group had a higher percentage of high-energy injuries,but this did not reach significance(72.9% vs 65.7%,P=0.082).Multivariate regression models showed that lower surgical volume(OR,5.8;95% CI,2.1-15.7;P=0.001)was independently associated with a higher risk of deep surgical site infection,bone implantation(OR,3.4;95% CI,0.9-12.9;P=0.075)was similar but not statistically significant,and other variables were not statistically significant.Multiple sensitivity analyses showed consistent clinical and statistical results.Conclusion: The study shows that there is an inverse relationship between the amount of orthopedic surgery and deep infection at the surgical site after displaced intra-articular calcaneal fracture surgery.Doctors need to maintain at least 6 cases of calcaneal fracture surgery every year to effectively prevent the occurrence of mental infection.Bone implantation has a tendency to increase the risk of deep infection and needs further study and confirmation,and attention should be paid in clinical practice.Part 2 Anatomical analysis of CT images of the normal calcaneus and its clinical significanceObjective: At present,with the rapid development of surgical techniques for calcaneal fractures and the continuous updating of internal fixation devices,it is more and more necessary and urgent to observe and measure the morphological characteristics of calcaneus in Chinese.In previous,there are few studies on calcaneal morphological measurement in Chinese,and lack of comparative studies on calcaneal morphological parameters of different ages.The measurement method based on X-ray and human specimen is easy to bring some problems,such as image overlap,manual measurement error,insufficient number of cases and so on.Therefore,by using the CT imaging data,we reconstruct the calcaneal model by Mimics technique,and then observed and measured the morphological parameters of calcaneal to explore the general rules of calcaneal morphological changes in Chinese with different genders and ages,which can provide reference and data support for the selection and design of new fixation devices and surgical schemes.Methods: According to the inclusion criteria,the imaging data of 120 patients who underwent ankle CT scanning in the Imaging Department of the third Hospital of Hebei Medical University from January 2022 to June 2022 were collected for preliminary screening.According to the exclusion criteria,95 qualified individual data were eventually retained for further analysis.The CT imaging data of these individuals were obtained from the workstation of the Imaging Department of the third Hospital of Hebei Medical University,and the Mimics technology was used for analysis and manual modeling.Various tools in the "Measure" toolbar of the software were used to measure and calculate the morphological parameters such as calcaneal volume,calcaneal surface area,calcaneal height,calcaneal sulcus height,posterior calcaneal height,calcaneal length,Gissane’ s angle,Bohler’ s angle,calcaneal width,calcaneal sulcus width,posterior calcaneal width,sustentaculum tali length,sustentaculum tali width and sustentaculum tali height.The work was carried out independently by two trained researchers and the intra-group correlation coefficient(ICC)was used to test the consistency of the results of the two researchers.Results: The ICC values of all the morphological parameters of the two researchers ranged from 0.826 to 0.982,showing a good consistency.For different genders,there was no significant difference in calcaneal volume,surface area,calcaneal sulcus height,posterior calcaneal height,calcaneal width,calcaneal sulcus e width,posterior calcaneal height,sustentaculum tali length,sustentaculum tali width,sustentaculum tali height,Gissane’s angle and Bohler’s angle.Compared with females,the parameters including calcaneal length and calcaneal height in males are larger,in which the difference of calcaneal height is statistically significant,and the difference of calcaneal length shows a statistically significant trend.For individuals at different age,there was no significant difference in calcaneal volume,surface area,calcaneal length,calcaneal height,calcaneal sulcus height,calcaneal sulcus width,sustentaculum tali length,sustentaculum tali width,sustentaculum tali height and Bohler’ s angle.Compared with individuals less than 60 years old,posterior calcaneal height and calcaneal width are samller and posterior calcaneal width and Gissane’s angle are larger in those 60 years old or more.The difference between calcaneal width and Gissane’s angle was statistically significant,and the difference between posterior calcaneal height and posterior calcaneal width showed a statistically significant trend.Conclusion: By measuring the morphological parameters of normal calcaneal model,we found that there were no significant differences in calcaneal volume,surface area,calcaneal sulcus height,calcaneal sulcus width,sustentaculum tali length,sustentaculum tali width,sustentaculum tali height and Bohler’s angle among different genders and ages.Compared with females,the measurement results of morphological parameters such as calcaneal length and calcaneal height in males were larger,while those 60 years old or more were smaller in calcaneal height and calcaneal width,and larger in calcaneal width and Gissane’s angle than those less than 60 years old.Part 3 Clinical comparative study of minimally invasive reduction and calcaneal self-localization navigation plate fixation versus open reduction and calcaneal anatomical plate internal fixation via extended lateral foot approach for the treatment of intra articular displacement fractures of the calcaneusObjective: Displaced intra-articular calcaneal fractures are the absolute indications for surgery.How to reduce the soft tissue complications after fracture surgery remains a major clinical challenge.Compared with traditional open surgery,minimally invasive surgery has been paid more and more attention in foot and ankle trauma,and is more and more widely used in clinical practice.Our team is committed to the minimally invasive and precise treatment of calcaneal fractures,developed the calcaneal self-positioning navigation plate,clinical application has been initially successful,the effect is significant;this study intends to carry out clinical research,with the classic lateral calcaneal extended approach open reduction and internal fixation of the calcaneal anatomical plate as the reference group,to explore the closed reduction,lateral longitudinal small incision approach of the hindfoot,calcaneal self-positioning navigation plate internal fixation comparison results,to expand the clinical application to provide data support.Methods: This study was a retrospective study.The patients with displaced intra-articular calcaneal fractures who underwent surgical treatment from August 2020 to July 2021 in the Third Hospital of Hebei Medical University and completed at least 12 months of follow-up after operation were identified by medical record search.The patients treated with open reduction and internal fixation of the calcaneal anatomical version through the classic lateral extended calcaneal approach were used as the reference group,and the patients who underwent closed reduction and lateral longitudinal small incision reduction and self-positioning navigation plate fixation of the calcaneus were used as the case group to form a cohort data source.In order to minimize differences in baseline data between the two groups,cases(minimally invasive group)and controls(open group)were reconstructed from the above data sources by propensity score matching(PSM)using propensity score matching(PSM)based on age,gender,residence(rural or urban),insurance type(public or self-paid medical care),fracture side,fracture severity(Sanders classification based on preoperative CT scan),and time interval from injury to surgery,which were statistically analyzed for outcome variables.For continuous variables,differences between groups were assessed using Student ’s t test or Mann Whitney-U test for independent samples;categorical variables were presented as frequencies and percentages,and differences were tested by Chi-square test or Fisher’ s exact test at a statistical level set at P<0.05.Results: Thirty-six patients were included in the minimally invasive group and 72 in the open group,with almost identical baseline variables(P>0.05).The operation time in minimally invasive group and open group was 62.5±16.4 min and107.4±26.3 min,respectively,and the difference had statistical significance(P<0.001).The incidence rate of complications in minimally invasive group was2.8%(1/36),which was significantly lower than that in open group(11.1%,8/72),but there was no statistical significance(P=0.140).No significant differences were found in Bohler angle measured immediately after surgery(27.8±6.2 vs 26.9±4.2,P=0.418)and loss of reduction rate at final follow-up(1/36 vs 3/72,P=0.719).AOFAS at the last follow-up between the two groups was 86.8±6.2 points in the MIS group and 87.3±7.9 points in the open group,with no statistical difference(P=0.795);similarly,no statistical difference was observed between the two groups in the excellent and good rate based on AOFAS score(91.7% vs 88.9%,P=0.653).Conclusion: For displaced intra-articular calcaneal fractures,minimally invasive reduction and internal fixation with self-positioning navigation plate through longitudinal small incision approach can significantly shorten the operation time,reduce the incidence of complications,and achieve the same clinical results compared with traditional open reduction and internal fixation with anatomical plate through lateral extended calcaneal approach,so it can be considered as an effective alternative for minimally invasive treatment of displaced intra-articular calcaneal fractures. |
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