Calcaneal Fractures - Should We or Should We not Operate?

Abstract

The best treatment for displaced, intraarticular fractures of the calcaneum remains controversial. Surgical treatment of these injuries is challenging and have a considerable learning curve. Studies comparing operative with nonoperative treatment including randomized trials and meta-analyses are fraught with a considerable number of confounders including highly variable fracture patterns, soft-tissue conditions, patient characteristics, surgeon experience, limited sensitivity of outcome measures, and rehabilitation protocols. It has become apparent that there is no single treatment that is suitable for all calcaneal fractures. Treatment should be tailored to the individual fracture pathoanatomy, accompanying soft-tissue damage, associated injuries, functional demand, and comorbidities of the patient. If operative treatment is chosen, reconstruction of the overall shape of the calcaneum and joint surfaces are of utmost importance to obtain a good functional result. Despite meticulous reconstruction, primary cartilage damage due to the impact at the time of injury may lead to posttraumatic subtalar arthritis. Even if subtalar fusion becomes necessary, patients benefit from primary anatomical reconstruction of the hindfoot geometry because in situ fusion is easier to perform and associated with better results than corrective fusion for hindfoot deformities in malunited calcaneal fractures. To minimize wound healing problems and stiffness due to scar formation after open reduction and internal fixation (ORIF) through extensile approaches several percutaneous and less invasive procedures through a direct approach over the sinus tarsi have successfully lowered the rates of infections and wound complications while ensuring exact anatomic reduction. There is evidence from multiple studies that malunited displaced calcaneal fractures result in painful arthritis and disabling, three-dimensional foot deformities for the affected patients. The poorest treatment results are reported after open surgical treatment that failed to achieve anatomic reconstruction of the calcaneum and its joints, thus combining the disadvantages of operative and nonoperative treatment. The crucial question, therefore, is not only whether to operate or not but also when and how to operate on calcaneal fractures if surgery is decided.

Keywords: Arthritis; Calcaneus; bone; calcaneal fracture; fracture fixation; fractures; internal fixation; malunion; nonoperative treatment; subtalar joint.

Figure 1

Standing x-ray lateral view of a 68 years old woman, 14 years postcalcaneum fracture showing severely displaced extraarticular calcaneal fracture. She can only wear sandals and clogs as a result of her tuberosity malunion

Figure 2

CT scan showing (a) Malreduction of a displaced, intraarticular calcaneal fracture despite open reduction and lateral plate fixation via an extensile approach. Such treatment combines the hazards and disadvantages of both operative and nonoperative treatment. Note the displacement of the peroneal tendons because of the displaced lateral fragment (red arrow). CT scan showing (b) A residual step-off in the subtalar joint which leads to significant load redistribution with the increased risk of posttraumatic arthritis. In the present case, there is complete loss of cartilage and cyst formation due to overload over the lateral aspect of the subtalar joint

Figure 3

(a) X-ray showing mildly displaced fractures without gross deformities of the heel for which nonoperative treatment is a good treatment option. (b-d) The computer tomography scans showing multiple fragmentation of the subtalar joint but with a minimal step-off of 1 mm

Figure 4

(a-d) Less invasive anatomic reduction and fixation of a displaced, intraarticular calcaneal fracture (Sanders Type 3 AB) in a 26-year-old male who sustained a fall from a roof. (e) The displaced posterior facet can be reduced under direct vision via the sinus tarsi approach. The reduction sequence is essentially the same as with an extensile approach. (f-h) Fixation is achieved with screws introduced percutaneously and a contoured interlocking plate that is slid in via the sinus tarsi approach and tunnelled beneath the peroneal tendons. Anatomic reduction is verified with intraoperative fluoroscopy. (i-k) Standing radiographs at 3 years followup show bony union without loss of correction and a congruent subtalar joint without signs of posttraumatic arthritis

Figure 5

(a and b) Sanders Type 3 BC fracture in a 36-year-old male who fell from a height of 1.5 m. Preoperative computed tomography scanning showing an additional multifragmentary fracture of the anterior process with joint displacement. Therefore, the sinus tarsi approach is extended to the calcaneocuboid joint. (c) Because the fracture lines are situated relatively far medially, dry arthroscopy is used for control of anatomic joint reduction. (d-f) Intraoperative fluoroscopy and postoperative computed tomography scans showing anatomic reconstruction of the overall shape of the calcaneum and its joints. (g) Uneventful appearance of the scar at 8 weeks followup. This case illustrates the necessity of individual planning of the therapeutic approach for displaced, intraarticular calcaneal fractures