Session V - Foot and Ankle

Operative Treatment of Calcaneal Fractures for Elderly Patients

Dolfi Herscovici, Jr., DO; James Widmaier, MD; Julia M. Scaduto, ARNP; Anthony Infante, DO; Roy W. Sanders, MD; Thomas G. DiPasquale, DO; Tampa General Hospital, Tampa, Florida, USA

Purpose: Patients less than 65 years of age have good results when managed with open reduction and internal fixation (ORIF) for displaced calcaneus fractures. The purpose of this study was to determine whether operatively treated calcaneal fractures in elderly patients had results similar to those of younger patients.

Methods: Between November 1987 and June 2000, 662 patients with calcaneal fractures were treated, with 583 undergoing open reduction and internal fixation. In this group, there were 42 patients over the age of 65 with 44 fractures. We could not locate 10 patients, 2 patients were excluded because of prior treatment, 1 refused follow-up, and 2 died, leaving 28 patients with 29 fractures available for follow-up. There were 15 men and 13 women with an average age of 69.7 years (range, 65 to 82). Twenty-one patients had significant underlying medical problems, none had diabetes and only 2 admitted to smoking. Mechanisms of injury were falls in 20, motor vehicle accidents in 7, and 1 from a lawn mower accident. Nineteen patients had isolated calcaneal fractures, and 9 were polytrauma patients. Twenty-seven fractures were displaced intraarticular fractures, 2 were displaced tuberosity fractures. There were four open fractures (in three patients). Fixation was delayed for all patients on an average of 16 days (range, 2 to 25) due to soft tissue compromise. All but one fracture was approached laterally and only one patient underwent a primary fusion. Evaluations included radiographs and SF-36, AOFAS, and SMFA scores.

Results: Twenty-eight of the fractures (97%), including the fusion, healed with the index treatment. Time to union averaged 113 days (range, 55 to 178), and patients were followed for an average of 38 months (range, 6 to 115). At final follow-up, 12 patients (46%) demonstrated radiographic signs of posttraumatic arthritis, and 3 underwent a subtalar fusion for pain management. Thirteen complications in 13 patients (43%) were identified. Four patients had wound edge necrosis, four had a painful hardware, three developed osteomyelitis, one had cellulitis, and one patient developed a nonunion. All patients who developed an infection or had wound problems had significant preexisting medical conditions. No infections or wound problems occurred among patients without medical comorbidities. Only the seven patients with osteomyelitis or the painful hardware underwent surgery. The average AOFAS score was 82.42 (range, 52 to 100), SF-36 general health scores averaged 52.81 (range, 40.4 to 63.9), and the SMFA score averaged 20.4 (range, 0.74 to 54.41).

Discussion and Conclusions: This study evaluated 28 patients over the age of 65 who underwent ORIF for displaced calcaneus fractures. Although reports in the literature do not support operative treatment for elderly patients, this population demonstrated results similar to those of younger patients when managed with fixation. There was a 97% union rate, and, although a high complication rate was noted, only four patients, excluding those with painful hardware, required surgical intervention. In addition, the development of posttraumatic arthritis did not seem to affect the functional outcome of these patients. Some elderly patients have high physical and recreational demands, and surgery for calcaneal fractures should not be denied on the basis of age. For patients who have significant medical comorbidities, care should be exhibited when considering operative management.