The Operative Treatment of Displaced Intra-articular Calcaneal Fractures (DIACFs): Long Term (10-20 years) Results in 108 Fractures using a Prognostic CT Classification

Roy Sanders, Zachary Vaupel, Murat Erdogan, Katheryne Downes
Journal of Orthopaedic Trauma 2014 June 30

OBJECTIVE: The primary purpose of this study was to determine whether the Sanders CT scan classification was still prognostic for outcome, when long term (10-20 years) radiographic and functional data of patients after ORIF for Sanders Type II versus Sanders Type III DIACFs were compared. The secondary purpose was to assess whether a bone graft or a locked plate was needed to maintain a reduction over time.DESIGN: prognostic case control study SETTING:: Level I trauma hospital PATIENTS:: Patients with operatively treated Sanders type II/III DIACF managed between 1/1/90 - 12/31/00 by a single surgeon were identified from a prospectively gathered database. Skeletally mature patients with a closed, isolated DIACF and a minimum of ten-year follow up were included in this analysis. All fractures were classified according to Essex-Lopresti and Sanders. 208/638 fractures met inclusion criteria.

INTERVENTION: Surgery consisted of a lateral extensile approach, posterior facet (PF) reduction, lag screw fixation, followed by reduction of the anterior process and tuberosity with the application of a non-locked lateral plate. Neither bone graft nor locking plates were used.

MAIN OUTCOME MEASURES: Articular congruity and overall reduction were assessed by CT scan and plain radiography (Böhler's and Gissane's angle) immediately postoperatively, and at the final follow-up examination in all patients. Functional assessment and outcome scores were obtained (AOFAS-AHS, Maryland, SF-36, AOS, and VAS), and all complications and/or subsequent surgeries were noted. A subtalar arthrodesis (STA) was considered a treatment failure, and was used as the determining outcome variable for comparing the two groups (II vs.

III). RESULTS: 108 fractures in 93 patients were available for F/U at a minimum of ten years (52%). Average F/U was 15.22 years (10.5-21.2 years). 80 were joint depression (J) and 28 were tongue type (T) fractures. There were 70 Sanders Type II and 38 Sanders Type III fractures. On immediate post-op CT scan, PF reduction was anatomic in 103 fractures (95%), near anatomic in 3 fractures (1-<3 mms), and approximate in 2 fractures (3-5 mm step). There were no failed reductions (>5 mm step). Long term results indicated that only 3 fractures settled, but no plates failed. There was 1 missed peroneal tendon dislocation. 7 patients had sural neuritis. 12 fractures (11%) required local wound care for apical necrosis. One patient had a dehiscence resulting in osteomyelitis requiring a subtalar (ST) fusion. 31 fractures (29 pts) developed ST arthritis, requiring an arthrodesis (30 ST, 1 triple) for unrelenting pain (VAS 8-10) during the F/U period resulting in an overall long term failure rate of 29%. Further breakdown by fracture type revealed that a ST fusion was performed in 47% of Type III fractures (18/38) versus only 19% in Type II (13/70) fractures (p=0.002). Type III fractures were four times more likely to need a fusion, compared to Type II's (RR=3.94; 95% CI: 1.64- 9.48).The remaining 66 patients (77 fractures) that did not require a fusion were evaluated for long-term functional outcome. Of these, only 1 patient used a cane, and only 1 (same patient) had a limp. 77% of the non-fused group (51/66) were within the U.S. norm for the SF-36 PCS, with 46% (30/66) above the norm. The average AOFAS-AHS was 75. The average VAS was 1.75, with scores of 0-1 (very little or no pain) seen in 56% of this subset of patients (37/66).

CONCLUSION: Based on the results of this comparative analysis, the Sanders classification remains prognostic; after a minimum of ten years, Type III fractures were four times more likely to need a fusion than Type II fractures. Secondarily, it appears that neither a locked plate, nor bone graft are required to maintain a reduction over time, as virtually no loss of reduction was seen in this series (3/108 = 0.9%). The "joint first" surgical treatment did not adversely affect CCJ outcome. Based on these results, if severe post-traumatic subtalar arthritis does not occur, long term (10-20 years) functional results with mild pain, minimal alterations in ADLs work, and essentially normal shoe wear can be expected from a properly performed ORIF. Patients must be counseled regarding difficulty with uneven ground and an inability to return to vigorous sports activities.

LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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