[Combined method of treating dislocated fractures of the calcaneus].

PURPOSE OF THE STUDY: The treatment of dislocated intraarticular fractures of calcaneus is still an unsolved chapter of traumatology. Our own poor long-term results of a purely conservative procedure has led us to develop a combined method of a direct and indirect reduction of calcaneus with the subsequent stabilization which we have been using since 1994. The basic principle of the method consists in the combination of a direct reduction of dislocated fragments of articular surfaces and indirect of calcaneus as a whole with the subsequent transfixation of calcaneus by K-wires.

MATERIAL: In the period of 1994-2001 we have treated in total 261 patients with 302 fractures of calcaneus, of which 218 were men (83.5%) and 43 women (16.5%) in the age range from 13 to 82 years (average age 45.1 years). By our own surgical method we treated 213 patients with 248 fractures, of which 180 were men (84.5%) and 33 women (15.5%) in the age range of 13-79 years (average age 44.8 years). Conservatively handled were 54 fracture in 48 patients. In the long-term followed up group we included 160 patients with 187 fractures operated on by identical method observing a minimum two-year interval after the operation. Of them 134 were men (83.8%) and 26 women (16.2%) in the age range of 15-75 years (average age 44.3 years). Of 248 operated on fractures of calcaneus 159 were joint-depression type (64.1%), 61 tongue type (24.6%) and 28 comminuted (11.3%) types of fractures. The time interval between the injury and operation ranged between 6 hours and 3 weeks (average 18.5 hours), however most patients we operated on on the day of injury.

METHODS: The basic principle of the method was a combination of a direct reduction of dislocated fragments of articular surfaces and indirect reduction of the calcaneus as a whole with a subsequent transfixation of the calcaneus by K-wires. After draping and setting of the image intensifier we proceeded to the actual surgery and divided the whole procedure of reduction and subsequent stabilization into 4 phases: Phase I--traction Phase II--elevation Phase III--compression Phase IV--transfixation In the first traction phase we inserted K-wire transversely through the distal-posterior edge of the calcaneus and connected it to the U-handle in order to achieve a proper effect of the traction. By traction distally along the long axis of the limb we restored the height and length of the calcaneus. Simultaneous pendular movements in eversion/inversion direction released the fragments and considerably facilitated the subsequent reduction. In the second, elevation phase the procedure differed according to individual types of fracture. In joint-depression type we inserted a blunt Steinmann pin or better a curved transpedicular elevator under the dislocated posterior articular surface through skin plantar stab incision and an ever-present primary transverse line of the fracture. In the tongue type of fracture we first introduced in the second phase a thick K-wire (3 mm) along the long axis of the tongue fragment and reduce the fragment by leverage elevation with a simultaneous continuous U-handle traction. After obtaining the desirable position we fixed the fragment by a K-wire vertically introduced from the upper part of calcaneal tuberosity (anteriorly and laterally from the origin of the Achilles tendon) towards the planta. If the medial part of the posterior articular surface remained dislocated we finished its reduction by means of elevator as in the preceding type of the fracture. The third and fourth phases of the surgical procedure was again identical for both types of fractures. In the third, compression phase we performed manually lateral compression of fragments under permanent traction. In the fourth, transfixation phase we first transfixed the reduced position of fragments formed by the primary longitudinal and transverse line. Under continuous radiograph checking in the lateral projection we inserted K-wires gradually from the lateral aspect, about 1.5 cm beneath the lateral malleolus into sustentacular fragment. Additional, mostly 2 K-wires we inserted under continuous traction and counter-traction along the long axis of the calcaneus and as the last step we drilled K-wires from the plantar side from calcaneal tuberosity into the fragments of the posterior articular surface.

RESULTS: In the group of long-term followed up patients we evaluated the Creighton-Nebraska Health Foundation score in 160 patients who were on average 43.4 months after operation. The obtained values of the score ranged between 63-100 points with the average of 83.9 points. In 27 patients the result was very good (16.9%), in 89 patients good (55.6%), in 24 patients fair (15.0%) and in 20 patients the result was poor (12.5%).

DISCUSSION: The first results of our method of 1998 have proved that it is necessary to combine the basic procedures of direct reduction of joint fragments, i.e. restoration of the calcaneus as a whole, namely in a strictly recommended sequence with a subsequent transfixation by K-wires. We do not use surgical procedures with open reduction and internal fixation (ORIF) differing mutually by the chosen surgical approach and the type of internal fixation used. As compared to ORIF our method has a significantly broader indication range. It can be used for the operation of patients regardless of the age, presence of associated diseases (diabetes, vascular affection) or local affection (a marked oedema, haematoma, non-infected skin blisters). The comparison of the general outcomes of the treatment in our group of patients, 72.5% of excellent and good results and only 12.5 of poor results, corresponds with the values of equally extensive foreign group of patients. In addition, as concerns the number of the incidence of deep infects in closed fractures (0.8%) the values in our group are in comparison several times lower and amputation of the limb was not necessary in any of the cases. It should be also noted that our group of patients has only a minimal indication limitation and operated on are also risk patients who never get in "filtered" groups treated by open method. Therefore it may be stated that the general results are in case of our method markedly better.

CONCLUSION: The proposed method requires neither a specialist nor any expensive technical equipment and as a result it may be used both at orthopaedic and surgical departments and due to its undemanding nature and short hospitalization it is also very acceptable from the economic viewpoint.