Fri., 10/5/12 Foot & Ankle, PAPER #42, 10:23 am OTA-2012
Operative Treatment of Displaced Intra-Articular Calcaneal Fractures: Long-Term (10-20 Years) Results in 108 Fractures Using a Prognostic CT Classification
Roy Sanders, MD; Zachary Vaupel, MD;
Florida Orthopaedic Institute, Tampa, Florida, USA
Background/Purpose: Although many short term studies using modern open reduction and internal fixation (ORIF) for displaced intra-articular calcaneal fractures (DIACFs) have shown an improvement in function, no study with long-term prospectively collected outcomes data exists. The purpose of this study was to evaluate the long-term (10-20 years) radiographic and functional outcome of patients after ORIF for DIACFs, and to determine whether the Sanders CT scan classification was still prognostic for outcome. The role of bone grafting and locked plating was also evaluated.
Methods: Isolated DIACFs managed with ORIF between January 1, 1990 and December 31, 2000 treated by a single surgeon were identified. All fractures were classified according to Essex-Lopresti, and Sanders et al. Surgery consisted of a lateral extensile approach, posterior facet (PF) reduction, lag screw fixation, and reduction of the anterior process/tuberosity with the application of a nonlocking lateral plate. No bone graft was used in any case. Articular (PF) reduction as measured by CT, Böhler angle, and Gissane angle was obtained postoperatively. At final follow-up (F/U) in 2011, all patients received plain radiographs, and a CT scan of the calcaneus. Functional assessment and outcome scores were obtained (Maryland, Short Form 36 [SF-36], and visual analog scale [VAS]), as well as all complications noted.
Results: 209 of 638 fractures met inclusion criteria: 108 fractures in 93 patients were available for F/U of a minimum 10 years (52%). Average F/U was 15.22 years (range, 10.5-21.2 years). 80 were joint depression (J) and 28 were tongue-type (T) fractures. There were 70 Sanders type II and 38 Sanders type III fractures. On immediate postoperative CT scan, PF reduction was anatomic in 103 fractures (95%), near anatomic in 3 fractures (1-3 mm), and approximate in 2 fractures (3-5 mm step). Long-term results indicated that only 2 fractures settled, at 4 and 7 years. No plates failed. There were no peroneal problems. Eight patients had sural neuritis. 12 fractures (11%) required local wound care for apical necrosis. One patient had a dehiscence resulting in osteomyelitis requiring a subtalar (ST) fusion. 31 fractures (29 patients) (29%) developed ST arthritis, requiring an arthrodesis (30 ST, 1 triple) for unrelenting pain (VAS, 8-10) during the F/U period. An ST fusion was performed in 47% of type III fractures (18 of 38) versus only 19% in type II (13 of 70) fractures (P = 0.002). In fact, type III fractures were roughly four times more likely to need a fusion compared to type II (RR = 3.94; 95% confidence interval [CI], 1.64-9.48).The remaining 66 patients (77 fractures) were evaluated for long-term functional outcome. Only one patient used a cane, and only one (same patient) had a limp. 85% had returned to their previous lifestyle. 77% of patients (51 of 66) were within the US norm for the SF-36 physical component summary, with 46% (30 of 66) above the norm. Based on the Maryland Foot Score, 72% of patients had good to excellent results (27 excellent, 32 good, 13 fair, 4 failures). VAS scores of 0 to 2 (very little or no pain) were seen in 74% of the patients (49 of 66).
Conclusion: Based on the results of this long-term analysis, the Sanders classification remains useful. The need for subtalar arthrodesis after ORIF for DIACFs, despite equally accurate articular reductions, is such that at a minimum of 10 years, type III fractures were roughly four times more likely to need a fusion compared to type II fractures. It appears that neither a locked plate nor bone graft are required to maintain a reduction over time, as virtually no loss of reduction was seen in this series. If posttraumatic subtalar arthritis does not occur, good long-term (10-20 years) functional results with little pain, a normal gait, and a return to previous lifestyle can be expected from a properly performed ORIF.
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