Session I - Foot & Ankle
Is Delayed Open Reduction Internal Fixation of Calcaneal Fractures Effective?
Purpose: Multiple studies support open reduction internal fixation (ORIF) of calcaneus fractures. There are many advantages to open reduction within the first several weeks following injury, primarily the ease of reduction. There is no current study supporting late ORIF of these injuries following delayed presentation. Many surgeons elect closed treatment or primary subtalar arthrodesis for those injuries presenting late or with treatment delayed for other reasons, as anatomic reduction becomes considerably more challenging. The purpose of the present study was to examine the outcome of a group of calcaneus fractures treated with ORIF 25 days or more after injury.
Methods: In a retrospective study at a level-one trauma center over an 8-year period (January 1994 to January 2002), 20 patients who sustained calcaneal fractures were treated with ORIF more than 25 days following injury. The OTA classifications of 73-A, 73-B, and 73-C injuries were included. All patients were treated by the senior author with ORIF with use of a lateral approach with standard AO fixation techniques. The goal of each operative procedure was anatomic reduction with restoration of calcaneal height, length, and alignment. The majority of patients (17, 85%) were treated with allograft bone graft. Radiographic and clinical follow-up was performed at regular scheduled intervals postoperatively. Bohler's angle was measured on injury radiographs, following operative fixation, and at final follow-up. These were compared with Bohler's angle of the contralateral uninjured extremity. Musculoskeletal Function Assessments (MFA) were conducted on all patients.
Results: Two patients were lost to follow-up, leaving 18 patients for data analysis. Eleven patients were male (61%), seven female (39%) with an average age of 39.8 years (range, 27 to 59). The mean number of days following injury to fixation was 33.4 (range, 26 to 58). The mechanism of injury was a fall for 13 and a motor vehicle accident for 5 patients. There was one open fracture. The majority of patients (15, 83%) were treated in a delayed manner as a result of either late referral from an outside institution or delayed until the patient was hemodynamically stable following multiple trauma. Two patients (11%) had delayed treatment secondary to fracture blisters. One patient (6%) was treated at 31 days following sepsis after operative treatment of a tibial plateau fracture. Eleven injuries were joint depression (OTA 73-C), with seven tongue-type (OTA 73-B, OTA 73-C) fracture patterns. Mean operative time including nerve block was 382 minutes (range, 240 to 640) with a mean estimated blood loss of 575 ml (range, 150 to 3500). Two patients (11%) had preoperative duplex evidence of deep venous thrombosis (DVT), both detected by ultrasound. Both were treated with a preoperative Greenfield filter. None of the isolated calcaneus fractures required blood transfusion following ORIF. There were no cases of postoperative infection. Eight patients (44%) developed symptomatic implants requiring removal. There were three total secondary operative procedures including one claw toe correction, one ankle cheilectomy with percutaneous tendo-Achilles lengthening, and one gastrocnemius slide with extraarticular calcaneal osteotomy. No patient required subtalar arthrodesis at an average of 25.6 months' follow-up (range, 3.5 to 100). Mean Bohler's angle at the time of injury was 10.9°, which corrected to a mean of 33.3° following operative fixation. Mean follow-up Bohler's angle decreased to a mean of 28.1° at final follow-up. Mean contralateral Bohler's angle was 32.3°.
Conclusion/Significance: The treatment of calcaneal fractures is controversial. Many techniques have been proposed for treating these injuries, ranging from closed treatment to primary subtalar arthrodesis. Studies indicate that nonoperative care is six times more likely to lead to subtalar arthrodesis as compared with ORIF. There are multiple studies supporting ORIF; however, there is no study detailing late open reduction of these fractures for injuries presenting late or for treatment delayed for other reasons. In this study ORIF was performed on 20 patients more than 25 days after injury. There were no postoperative infections, and no patient required subtalar arthrodesis at a mean of 25.6 months. Only one patient required an extraarticular osteotomy at 1.5 years following ORIF secondary to a tuberosity malunion. Bohler's angle increased on average 22.4° after operative fixation. Mean Bohler's angle decreased only 5.2° from the time of operative fixation to the final follow-up. The preceding data suggest that formal ORIF is a viable and safe surgical option for patients with a calcaneal fracture presenting in a delayed manner. Formal anatomic operative reduction is successful in treating these injuries with a low incidence of complications. Primary subtalar arthrodesis should be reserved for late sequelae of calcaneus fractures following ORIF.