On Which Calcaneal Fractures Do You Operate?
From the fracture surgeon’s perspective, the calcaneus is a cortical shell surrounded by a fragile soft-tissue envelope with the articular surfaces supported by an internal network of cancellous bone. Axial loading is the common mechanism of injury, resulting in a number of different possible injury patterns and deformities of the calcaneus. This includes injury to the articular surfaces of the posterior, middle, and anterior facets of the subtalar joint and the calcaneo-cuboid joint. The supporting subchondral bone of the subtalar joint is always depressed and often comminuted. The tuberosity may be displaced cephalad, medially into adduction, rotated into varus, shortened along the oblique primary fracture line, or a combination of these deformities. The heel is widened as the lateral wall and occasionally medial wall are displaced. In addition, the surrounding soft tissues are damaged by the initial trauma, displacement of bony fragments, and the resultant swelling.
Controversy exists as to how much deformity can be accepted. Regardless, it is clear that injury and residual incongruity of the articular surfaces predisposes to loss of motion and post-traumatic arthritis. The depression of the central calcaneus affects the subtalar joint, but also enables the talar body to settle into dorsiflexion, compromising the function of the ankle. Persistent widening of the lateral wall often results in impingement and peroneal tendon problems. These problems plus the deformities of the heel as noted above can result in chronic pain and swelling, gait disturbances, shoe wear problems, and functional and vocational limitations.
As a result, the goals in treating these displaced intra-articular fractures are to restore the articular surfaces and supporting bone using fixation with sufficient stability to maintain this alignment and permit early motion of the injured joints. Numerous studies have shown that these goals can be achieved, but the complication rates are high primarily due to compromised soft tissues and patient comorbidities.1 Despite the complication rates, it is generally believed that open reduction and internal fixation (ORIF) of these fractures gives better results than nonoperative treatment. However, in this era of evidence-based medicine, this has been difficult to prove.
Buckley,2 in a series of studies resulting from a prospective, randomized, controlled multicenter trial on operative compared with nonoperative treatment of displaced intra-articular calcaneus fractures, found that some subgroups of patients had better outcomes after surgical treatment. Better outcomes were noted in females, younger patients, and patients who did not have to return to heavy workloads and/or were not receiving workers compensation. Patients with lower classification grades (ie, less comminution), anatomic reduction of the posterior facet or a step off of <2 mm, and restoration of Bohler’s angle also had better outcomes. Unfortunately, the remaining patients (males, overweight, higher degrees of comminution, heavy workload, work-related) did not do well with nonoperative treatment either. The question therefore remains: Which fractures in which patients should be treated with ORIF?
My indications for ORIF in these fractures include:
* Two- or three-part fractures of the posterior facet (Sanders Type II or III) with depression of the articular surfaces more than 2 mm to 3 mm on computed tomography (CT) scan
* Displacement of the lateral wall of the calcaneus beyond the lateral edge of the fibula (patients may have symptomatic impingement with less displacement but they are all symptomatic with this much displacement)
* Displacement of the tuberosity resulting in compromise of the soft tissues or a hindfoot deformity that will cause problems with shoe wear and walking, especially a varus and/or adduction malunion of the heel
* Soft tissues suitable for surgical treatment
* Patient suitable for surgical treatment (A detailed and thorough informed consent is essential. In terms of patient comorbidities, diabetes, obesity, peripheral vascular disease, and smoking seem to be particularly important risk factors.)
Some of these fractures are amenable to percutaneous reduction and fixation techniques. If the articular surfaces are restored and the surrounding bone is realigned, the results of these techniques seem comparable to those with formal open reduction utilizing an extensile exposure. However, more study of these minimally invasive options is needed. There also may be a role for percutaneous techniques to improve the alignment of the heel when soft tissue compromises and patient factors preclude an open reduction.
The highly comminuted calcaneus fracture (Sanders IV) is probably destined to need a subtalar fusion. The unresolved question is whether to do this as a primary procedure (when soft tissue permits) or as a delayed reconstruction.
Finally, it should be noted that surgeon experience is important in treating these injuries. These are difficult fractures not well-suited for the occasional fracture surgeon. The surrounding soft tissues are unforgiving and resulting problems difficult to salvage. Open internal fixation (ie, without reduction) exposes patients to all the risks of operative treatment but few of the benefits. Fractures of the calcaneus are seldom emergencies, so there is ample time for a thorough evaluation, observation of the soft tissues, and transfer of the patient, if needed.
Figure 39-1A. Lateral radiograph: Intra-articular fracture of the calcaneous.
Figure 39-1B. Coronal CT scan shows displacement of the posterior facet and the lateral wall of the calcaneous with subfibular impingement.
Figure 39-1C. Postoperative radiograph after open reduction and internal fixation.
1. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000;82:225-250.
2. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures. J Bone Joint Surg Am. 84:1733-1744.