Session III - Reconstruction

Thurs., 10/5/06 Reconstruction, Paper #16, 4:54 pm

Subtalar Fusion after Displaced Intra-Articular Calcaneal Fractures (DIACFs): Does Initial Operative Treatment (ORIF) Really Matter?

Craig S. Radnay, MD, MPH (n); Michael P. Clare, MD (n);
H. Claude Sagi, MD (n); Roy W. Sanders, MD (n);
Florida Orthopaedic Institute, Tampa, Florida, USA

Purpose: Our objective was to determine whether initial operative treatment of DIACFs has any benefit over initial nonoperative treatment after late posttraumatic arthritis develops and a subsequent subtalar arthrodesis is required.

Methods: There were 69 patients (75 fractures) with DIACFs that subsequently underwent subtalar arthrodesis for painful posttraumatic arthritis. The patients were separated into two groups: Group A, those initially treated with open reduction and internal fixation (ORIF); and Group B, those initially treated nonoperatively. The groups were homogeneous for age, sex, mechanism of injury, and smoking. Group A consisted of 36 fractures (34 patients), initially treated surgically. In situ subtalar fusion for symptomatic arthritis was performed at an average of 22.6 months (range, 5.5-106) after ORIF. Group B consisted of 39 fractures (35 patients) treated nonoperatively. All patients presented due to a symptomatic malunion, and underwent reconstruction and fusion according to the method of Stephens and Sanders. Fusion was based on radiographs. Return to work and final functional outcome was assessed using the Maryland Foot Score (MFS) and AOFAS Ankle and Hindfoot Scale (AHS) at a minimum of 24 months.

Results: All 69 patients in this study were available for follow-up (F/U) (100%). Group A had an average F/U of 32.5 months (range, 26-141); Group B had an average F/U of 63.5 months (range, 46-122). Group A trended to a greater number of workers' compensation claims vs. Group B (A = 67%; B = 44%: P = 0.0635). Both groups had 3 nonunions requiring revision. Group A had fewer wound complications following fusion than Group B: delayed wound healing (11.1% vs. 28.2%, P = 0.0856); wet-to-dry dressings (8.33% vs. 25.64%, P = 0.0676); whirlpool treatment (2.78% vs. 25.64%, P = 0.0072); and prolonged antibiotic treatment, >6 weeks (5.6% vs. 28.2%, P = 0.0134). Group A scores were significantly higher than Group B with respect to both the MFS (90.81 vs. 79.13, P <0.0001) and AHS (87.08 vs. 73.82, P <0.0001).

Conclusion: If symptomatic subtalar arthritis develops after a DIACF, a fusion will be needed. Based on our data, subtalar fusion following initial ORIF of DIACFs is associated with a better functional outcome and fewer operative risks, including wound complications, than fusion after initial nonoperative treatment (resultant calcaneal malunion). We believe that restoration of calcaneal shape at the time of initial ORIF is the principal variable making the subsequent fusion both surgically easier and functionally better.

Significance: Initial ORIF of DIACFs is associated with significantly better clinical outcomes and greater overall long-term patient benefit, even if painful posttraumatic subtalar arthritis requires subsequent arthrodesis.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
· The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an "off label" use). · · FDA information not available at time of printing.