Session IX - Foot & Ankle

Operative Treatment of 635 Displaced Intra-articular Calcaneal Fractures

Anthony F. Infante, Jr. DO; Keith Heier, MD;Thomas DiPasquale, DO; Arthur Walling, MD; Dolfi Herscovici, DO; Roy Sanders, MD, Florida Orthopedic Institute, Tampa, FL

Introduction: The treatment of calcaneus fractures with open reduction and internal fixation (ORIF) to restore the calcaneus and hindfoot anatomy can be performed with minimal complications and good functional results.

Methods: Between 1987 and 1997, 635 displaced intra-articular fractures were treated with ORIF at our level 1 trauma center. Thirty-four of the 635 were open fractures and 55 were lost to follow-up, leaving us with 546 closed intra-articular calcaneal fractures treated with ORIF. Follow-up was from 2 to 11 years. There were 246 Sanders Type II fractures, 216 Sanders Type III fractures and 84 Sanders Type IV fractures. Data were collected by reviewing hospital and office charts, radiographs and with patient follow-up. Creighton-Nebraska, AOFAS, Maryland Foot and SF-36 questionnaire results were recorded during the patients' last follow-up.

Results: Despite the complexity of intra-articular comminution and the shape of the soft tissue envelope, 543 of the 546 Sanders Types II, III and IV calcaneal fractures united within 4 months. Roentgenographic evaluation of calcaneal body dimensions showed restoration of heel height (98%), width (105%) and length (99%) to near normal regardless of the severity of the fracture. Roentgenographically, articular reduction was anatomic in 220 of 246 (89%) Type II fractures, 153 of 216 (71%) Type III fractures and 44 of 84 (52%) of the Type IV fractures. Complications (8%) included 29 wound dehiscences, 12 patients with osteomyelitis and 1 nonunion. Two of the patients with uncontrolled osteomyelitis needed below knee amputations. Eighty-three patients underwent removal of painful hardware after the fracture was healed. The average AOFAS, Creighton-Nebraska and Maryland Hindfoot scores were 89, 88 and 83 respectively for Type II fractures, 73, 68 and 73 for Type III fractures, 49, 40 and 59 for Type IV fractures, and 78, 61 and 81 for Type IV fractures treated with ORIF and primary fusions.

Conclusion: Displaced intra-articular calcaneal fractures can be treated safely and effectively with ORIF via a single lateral incision. Anatomic restoration of hindfoot anatomy is necessary for a good functional outcome, although it does not guarantee one. In cases with severe cartilage damage, ORIF with primary fusion is recommended.