Session VII - Foot and Ankle

Treatment of Open Intraarticular Calcaneal Fractures: Evaluation and Rate of Soft Tissue Complication for a Treatment Protocol Based on Wound Location and Size

Steven J. Thornton, MD¹; Domingo Cheleuitte, MD¹; Amy J. Ptaszek, MD²; John S. Early, MD¹;

¹University of Texas Southwestern Medical Center, Dallas, Texas, USA;

²Illinois Bone and Joint Clinic, Chicago, Illinois, USA

Purpose: Treatment protocols for the management of closed displaced intraarticular calcaneal fractures and their soft tissue complications are well-documented. Effective treatment algorithms for open displaced intraarticular calcaneal fractures and their potential early complications have not yet been established. We retrospectively reviewed the management of open displaced calcaneal fractures at a level I trauma center and their resulting soft tissue complications in an effort to establish guidelines for management.

Method: At a single level-I trauma center, 328 displaced intraarticular calcaneal fractures in 302 patients were seen and operatively treated between November 1994 and April 2002. Thirty-two of these fractures in 30 patients were open injuries (10%). One was treated solely with an external fixator and excluded from the study. All open fractures underwent a standard treatment protocol based on wound position, size, and subsequent soft tissue behavior in the first 10 days after injury. All open wounds underwent serial debridement every 24 to 48 hours until clean (1 to 3 times). All fractures were manually reduced after each debridement of the wound to reduce skin tension caused by a displaced tuberosity. For consideration for subsequent open reduction and internal fixation via a lateral approach, the wound had to be located on the medial aspect of the foot, sutured closed after the final debridement, and had to be stable without evidence of infection while the patient did not take antibiotics for 10 days. Those cases that did not meet these criteria were treated with manual reduction of the tuberosity through the open wound and held with percutaneous wires from the tuberosity to the talus; the soft tissue wound was managed as necessary. Treatment of lateral wounds involved extensive debridement until the soft tissue was stable, and then limited fixation was used to stabilize displaced fractures at the time of lateral wound closure or flap coverage. Wounds were described according to location and to the Gustillo-Anderson classification, and fractures were described according to the AO-OTA classification. Data on associated injuries, comorbidities, smoking, and subsequent soft tissue complication were collected and reviewed. Return to the operating room for care of the traumatic wound or any complication from any surgical wound at the calcaneus was recorded as a complication.

Results: Thirty-one open calcaneal fractures were reviewed. There were four fractures with lateral soft tissue wounds: Gustillo-Anderson II (1), III (3). The associated calcaneal fractures, as defined by the AO-OTA system, included one 73-C2 and three 73-C3. Two underwent limited internal fixation at the time of wound closure, and two underwent fracture stabilization with percutaneous wires. All patients had multiple extremity injuries. There was a 50% infection rate with both methods of treatment, requiring further surgical debridement from deep infection with resultant free tissue transfers required. There were no amputations in this group.

Twenty-seven fractures presented with a medial wound: Gustillo-Anderson I (16), II (7), III (4). There was no correlation between wound grade and underlying fracture severity. In accord with the protocol, 18 patients underwent open reduction internal fixation through a lateral approach, and 9 underwent reduction and percutaneous pinning of the tuberosity. There was an overall wound complication rate of 28% (5 of 18) in the open reduction internal fixation group and 22% (2 of 9) in those receiving reduction and percutaneous pinning.

In the open reduction internal fixation group, one free tissue transfer was required, three cases of osteomyelitis were seen, and one resultant amputation was noted in a patient with concomitant compartment syndrome of the injured foot. Those with a wound of less than 4 cm that underwent open reduction internal fixation had a wound complication rate of 14% (2 of 14), as compared with a complication rate of 67% (2 of 3) in those with a stable closed traumatic wound that was 4 cm or larger. Nine patients whose wounds were not closable nor stable after multiple debridements had greater concerns all emanating from the traumatic wound. In all cases, the tuberosity was reduced and held with percutaneous wires. Those with a 4-cm or larger wound had a complication rate of 29% (2 of 7), whereas those with a less than 4-cm wound that received percutaneous pinning had no complications. With aggressive soft tissue management, the resultant complications in this high-risk group included one pin tract infection and only one amputation.

Conclusion: The management of open calcaneal fractures and the risk of complications should be based on the size and position of the traumatic wound. Lateral wounds have a high complication rate independent of methods for fracture stabilization. Medial wounds of less than 4 cm can be treated successfully with open reduction internal fixation if the wound can be closed and remains stable without the use of antibiotics. Larger wounds or unstable wounds should not undergo formal open reduction internal fixation because of the observed increased complication rate. Instead, they should be reduced and held in alignment with percutaneous wire fixation with much less risk.