Fri., 10/9/09 Pilon/Foot & Ankle, Paper #58, 4:34 pm OTA-2009

Primary Subtalar Fusion for Unreconstructible Intra-Articular Calcaneal Fractures: Intermediate to Long-Term Results

Gregory P. Witkowski, MD (n); Arthur K. Walling, MD, III (4, 7-AO; 7, 8-DePuy, A Johnson & Johnson Company; 7-DJ Orthopaedics; Encore Medical; Johnson & Johnson; Smith & Nephew; Stryker; Zimmer; 7, 10-Link Orthopaedics; 8-Merck);
Roy Sanders, MD (2-Wolters Kluwer Health - Lippincott Williams & Wilkins: Journal of
Orthopaedic Trauma; 3-Linvatec; 3, 7-Stryker; 3, 5A, 7-Smith & Nephew; 3,7-DePuy, A Johnson & Johnson Company; 7-Pfizer);
Florida Orthopaedic Institute, Orthopaedic Trauma Service, Tampa, Florida, USA

Purpose: Severely comminuted intra-articular calcaneal fractures that cannot be anatomically reduced have a high rate of post-traumatic arthritis and the need for subsequent subtalar arthrodesis. This study examined the clinical and radiographic outcomes of patients treated with open reduction internal fixation (ORIF) followed by an immediate primary subtalar arthrodesis (PSTA) for unreconstructible displaced intra-articular calcaneal fractures.

Methods: Between 1990 and 2007, thirty-two patients with thirty-five unreconstructible Sanders Type III/IV calcaneal fractures were treated with ORIF/PSTA. An ORIF was performed through an extensile lateral approach to restore calcaneal height and alignment. Primary arthrodesis was then immediately performed by debriding the joint of any remaining cartilage, bone grafting defects, and using cannulated screws in a standard fashion. Pre- and postoperative radiographs were reviewed to determine fracture classification, time to union, and radiographic parameters. Patients were contacted for follow up and outcome measures.

Results: Fifteen patients with seventeen fractures were available for follow up at a mean of 9.8 years (range 2 to 19.6). There were 2 nonunions requiring revision, 1 wound dehiscence, 1 deep infections requiring irrigation and debridement, and 5 symptomatic cannulated screws requiring late removal. Mean AOFAS hindfoot score was 74.9 + 12.9 SD and mean Maryland foot and ankle score was 79.8 + 11.4 SD. A correlation between talocalcaneal height and outcome scores was observed (p < .05). Polytrauma patients had significantly lower outcome scores than patient with isolated injuries (p < .05).

Conclusion: Our intermediate to long-term data demonstrate that ORIF followed by an immediate primary subtalar arthrodesis as a salvage procedure for unreconstructible calcaneal fractures yields satisfactory results with an acceptable rate union. Every attempt should be made by the surgeon to adequately restore calcaneal anatomy including talocalcaneal height before the fusion is attempted.

Disclosure: (n=Respondent answered 'No' to all items indicating no conflicts; 1=Board member/owner/officer/committee appointments; 2=Medical/Orthopaedic Publications; 3=Royalties; 4=Speakers bureau/paid presentations; 5A=Paid consultant or employee; 5B=Unpaid consultant; 6=Research or institutional support from a publisher; 7=Research or institutional support from a company or supplier; 8=Stock or Stock Options; 9=Other financial/material support from a publisher; 10=Other financial/material support from a company or supplier).

• 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. Δ OTA Grant