Surgical treatment of type IV Zwipp – Rammelt calcaneal fractures using customized resection templates

Introduction Calcaneal fractures account for approximately 2 % of all fractures and are common in younger population. Treatment of the patients can be challenging with involved articular and soft tissue component. Conventional methods can be ineffective for complex and rare type IV and type V Zwipp – Rammelt fractures necessitating development of new surgical approaches.

The objective was to explore short-term (10 months of observation) outcomes of patients with type IV Zwipp – Rammelt calcaneal fractures using a new technology. The technique suggested improved accuracy of remodeling osteotomy due to three-dimensional reconstruction of the broken foot during preoperative planning and creation of customized resection templates with additive technologies.

Material and methods A prospective, hypothesis-generating study was performed for 13 patients with type IV Zwipp – Rammelt calcaneal fractures. There were 6 males and 7 females with the mean age of 45.5 ± 13.02 years. The patients were treated with the new method which employed 3D reconstruction of the broken foot using MSCT images, fabrication of customized resection templates using FDM printing, their sterilization with ethylene oxide, precision osteotomy of the calcaneus through an L-shaped approach and subtalar arthrodesis. The results were assessed at 77 weeks using AOFAS, EFAS, FFI and VAS scales.

Results Functional parameters significantly improved at ten months with the EFAS increased by 2.5 times (to 34.0 scores, p = 0.0002), AOFAS improved by 1.6 times (to 80.0 scores, p = 0.0002), FFI increased by 1.57 times (to 38.0 scores, p = 0.0002). Pain improved with the VAS decreasing by half from 60 mm to 30 mm (p = 0.001).

Discussion The technique demonstrated several advantages with the possibility of multiplanar osteotomies, precise template fixation and control of resection parameters facilitating anatomical restoration.

Conclusion Short-term outcomes of patients with type IV Zwipp – Rammelt calcaneal fractures showed that custom-made resection templates were practical for accurate surgical technology, improved functional outcomes, pain relief using the effective technique.

1. Alrashidi YA, Sonbol AM, Abuseer HO, et al. Calcaneal fractures in a trauma center: A retrospective study. J Musculoskelet Surg Res. 2021;5(2):116-120. doi: 10.4103/jmsr.jmsr_10_21.

2. Tufescu TV, Buckley R. Age, gender, work capability, and worker's compensation in patients with displaced intraarticular calcaneal fractures. J Orthop Trauma. 2001;15(4):275-279. doi: 10.1097/00005131-200105000-00007.

3. Lawrence SJ. Open calcaneal fractures. Orthopedics. 2004;27(7):737-741; quiz 742-3. doi: 10.3928/0147-7447-20040701-14.

4. Sikora H, Kopeć K, Dudko S, et al. Chronic, Neglected Medial Subtalar Dislocation with Associated Talar and Calcaneal Fractures. A Case Report. Ortop Traumatol Rehabil. 2022;24(1):61-67. doi: 10.5604/01.3001.0015.7808.

5. Kang D, Raviprasad A, Pierre K, et al. Challenges in diagnosis of calcaneal fractures: an examination using the WIDI SIM platform. Emerg Radiol. 2024;31(5):653-660. doi: 10.1007/s10140-024-02267-5.

6. Rammelt S, Zwipp H. Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: indications, techniques, results. Int Orthop. 2013;37(9):1707-1717. doi: 10.1007/s00264-013-2021-3.

7. Shibuya N, Simmons A, Felix F. Posterior Arthroscopic Subtalar Joint Arthrodesis (Pasta). Clin Podiatr Med Surg. 2023 Jl;40(3):471-481. doi: 10.1016/j.cpm.2023.02.002.

8. Ebben BJ, Myerson M. Management of the Subtalar Joint Following Calcaneal Fracture Malunion. Foot Ankle Clin. 2022;27(4):787-803. doi: 10.1016/j.fcl.2022.08.001.

9. Saß M, Rotter R, Mittlmeier T. Minimally invasive internal fixation of calcaneal fractures or subtalar joint arthrodesis using the Calcanail®. Oper Orthop Traumatol. 2019;31(2):149-164. doi: 10.1007/s00064-018-0576-2.

10. Romash MM. Reconstructive osteotomy of the calcaneus with subtalar arthrodesis for malunited calcaneal fractures. Clin Orthop Relat Res. 1993;(290):157-167.

11. Romash MM. Reconstructive oblique calcaneal osteotomy with subtalar arthrodesis for malunited calcaneal fractures. Tech Foot Ankle Surg. 2006;5(4):239-249. doi: 10.1097/01.btf.0000235009.21478.95.

12. Guang-Rong Y, Xiao Y. Surgical Management of Calcaneal Malunion. J Orthop Trauma Rehabil. 2013;17(1):2-8. doi: 10.1016/j.jotr.2012.04.001.

13. Yu GR, Zhang MZ, Yang YF. Corrective Osteotomies for Malunited Tongue-Type Calcaneal Fractures. Foot Ankle Clin. 2016;21(1):123-134. doi: 10.1016/j.fcl.2015.09.005.

14. Pahomov IA. Development of biomechanically reasoned method of treatment of patients with consequences of calcaneus fractures consolidated in faulty position and complicated with extensive contracture of ankle joint. Politravma. 2010;(4):24-29. (in Russ.)

15. Pahomov IA. Surgical method for treating talocrural articulation contracture. Patent RF, no. 2322205, 2008. Available at: https://www1.fips.ru/Archive/PAT/2008FULL/2008.04.20/DOC/RUNWC2/000/000/002/322/205/DOCUMENT.PDF. Accessed 18 Mar 2025. (In Russ.)

16. Kuznetsov VV, Protsko VG, Mazalov AV, et al. Method for surgical management of heel bone fractures consolidated in position of displacement with posttraumatic deformations of hindfoot. Patent RF, no. 2829420, 2024. Available at: https://fips.ru/publication-web/publications/document?type=doc&tab=IZPM&id=51B5251B-7843-4E49-849B-BF78EB2F3E7A. Accessed 18 Mar 2025. (In Russ.)

17. Richter M, Zech S, Geerling J, et al. A new foot and ankle outcome score: questionnaire based, subjective, visual-analogue-scale, validated and computerized. Foot Ankle Surg. 2006;12(4):191-199. doi: 10.1016/j.fas.2006.04.001.

18. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15(7):349-353. doi: 10.1177/107110079401500701.

19. Budiman-Mak E, Conrad KJ, Roach KE. The Foot Function Index: a measure of foot pain and disability. J Clin Epidemiol. 1991;44(6):561-570. doi: 10.1016/0895-4356(91)90220-4.

20. Richter M, Agren PH, Besse JL, et al. EFAS Score - Multilingual development and validation of a patient-reported outcome measure (PROM) by the score committee of the European Foot and Ankle Society (EFAS). Foot Ankle Surg. 2018;24(3):185-204. doi: 10.1016/j.fas.2018.05.004.

21. Pahomov I. A. Surgical tactics and organization of specialized care for patients with orthopedic pathology of the foot and ankle joints. Author's abstract Doct. Diss. Novosibirsk, 2012:42. Available at: https://search.rsl.ru/ru/record/01005009776. Accessed 18 March 2025. (In Russ.)

22. Zwipp H, Rammelt S, Barthel S. Calcaneal fractures--open reduction and internal fixation (ORIF). Injury. 2004;35 Suppl 2:SB46-54. doi: 10.1016/j.injury.2004.07.011.

23. Lee JY, Tan BM, Png W, et al. Novel utilization of 3D printing technology for a chronic malunited calcaneum fracture - a case report. Foot Ankle Surg Tech Rep Cases. 2021;1(3):100051. doi: 10.1016/j.fastrc.2021.100051.

24. Schepers T. The subtalar distraction bone block arthrodesis following the late complications of calcaneal fractures: a systematic review. Foot (Edinb). 2013;23(1):39-44. doi: 10.1016/j.foot.2012.10.004.

25. Qiang M, Zhang K, Chen Y, et al. Computer-assisted virtual surgical technology in pre-operative design for the reconstruction of calcaneal fracture malunion. Int Orthop. 2019;43(7):1669-1677. doi: 10.1007/s00264-019-04328-8.