[Operative treatment of displaced intra-articular calcaneal fractures]

H Zwipp, S Rammelt, M Amlang, M Pompach, C Dürr
Operative Orthopädie und Traumatologie 2013, 25 (6): 554-68

OBJECTIVE: Anatomic reduction of displaced intra-articular calcaneal fractures with restoration of height, length, and axial alignment and reconstruction of the subtalar and calcaneocuboid joints.

INDICATIONS: Displaced intra-articular calcaneal fractures with incongruity of the posterior facet of the subtalar joint, loss of height, and axial malalignment.

CONTRAINDICATIONS: High perioperative risk, soft tissue infection, advanced peripheral arterial disease (stage III), neurogenic osteoarthropathy, poor patient compliance (e. g., substance abuse).

SURGICAL TECHNIQUE: Extended lateral approach with the patient placed on the uninjured side. Reduction of the anatomic shape and joint surfaces according to the preoperative CT-based planning. Reduction of the medial wall and step-wise reconstruction of the posterior facet from medial to lateral. Reduction of the tuberosity and anterior process fragments to the posterior joint block and temporary fixation with Kirschner wires. Internal fixation with an anatomic lateral plate in a locking or nonlocking mode. Alternatively less invasive internal fixation with a calcaneus nail over a sinus tarsi approach for less severe fracture types.

POSTOPERATIVE MANAGEMENT: The lower leg is immobilized in a brace until the wound is healed. Range of motion exercises of the ankle and subtalar joints are initiated on the second postoperative day. Patients are mobilized in their own shoe with partial weight bearing of 20 kg for 6-12 weeks depending on fracture severity and bone quality.

RESULTS: Over a 4-year period, 163 patients with 184 displaced, intra-articular calcaneal fractures were treated with a lateral plate via an extended approach. In all, 102 patients with 116 fractures were followed for a mean of 8 years. A surgical revision was necessary in 4 cases (3.4%) of postoperative hematoma, 2 (1.7%) superficial and 5 (4.3%) deep infections. Of the latter, 2 patients needed a free flap for definite wound coverage, no calcanectomy or amputation was needed. Secondary subtalar fusion for symptomatic posttraumatic arthritis was performed in 9 cases (7.8%). At follow-up, the AOFAS Ankle/Hindfoot Score averaged 70.2, the Zwipp Score averaged 76.0, the German versions of the Foot Function Index and SF-36 physical component averaged 32.8 and 42.2, respectively. Scores were significantly lower with increasing fracture severity according to the Sanders and Zwipp classifications, bilateral fractures, open fractures, and with work-related injuries. With less invasive fixation using a calcaneal nail, superficial wound edge necrosis was seen in 2 of 75 cases (2.7%).

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