Session VIII - Foot and Ankle

The Essex-Lopresti Reduction for Calcaneal Fractures Revisited

Paul Tornetta, III, MD

University Hospital, Brooklyn, New York, USA

Purpose: To evaluate the reduction and outcome of intraarticular calcaneal fractures treated with a percutaneous Essex-Lopresti reduction and fixation.

Methods: A prospective series of 26 calcaneal fractures meeting inclusion criteria were treated with a percutaneous Essex-Lopresti spike reduction and fixation over a 4-year period. All fractures were tongue type and Sanders type 2C (OTA type 73-Cl.3) with the entire posterior facet of the calcaneus displaced from the sustentaculum and impacted into the body. Five cases also had secondary fractures into the calcaneo-cuboid joint. Reductions were performed percutaneously under fluoroscopic control with the patient in the lateral position. Twenty-three of the 26 feet had an acceptable reduction and the remaining 3 were treated with ORIF. The first 17 cases were stabilized by 2 Steinmann pins which were removed at 10 - 12 weeks. The last 6 cases were fixed with 2 cannulated 6.5 mm screws which were left in place. Early motion was encouraged in all cases.

Results: Of the 23 with an acceptable reduction, 20 had no angulation between the posterior facet of the talus and the calcaneus and 3 had < 5°. The tuberosity reduction was < 5° in 17 cases and < 10° in all cases. The calcaneal height was restored to normal in 20 cases and the width (axial view) averaged 119% of the contralateral side. One patient died (leaving 22 for the clinical evaluation), one had a mild loss of height during healing, and 4 had superficial pin tract infections; there were no other complications. Follow-up averaged 2.1 years. Using the Maryland foot score there were 12 (55%) excellent, 7 (32%) good, and 3 (13%) fair results.

Discussion: The percutaneous spike reduction described by Essex-Lopresti is rarely indicated, but is useful in tongue type fractures in which there are no fracture lines through the posterior facet. These are type 2C by the Sanders CT classification scheme. The majority of these cases are reducible using this technique and can be held to union. The clinical outcome of these 22 cases is better than the outcome of intraarticular fractures treated by the same surgeon using ORIF via an extended lateral approach (87% vs. 77% good or excellent) and superior to other reports of ORIF graded with the Maryland foot score. Several factors may be responsible for this difference including the fact that the posterior facet has no fractures through it, but the lack of a large incision and stripping are also likely to be factors in improving outcome.

Conclusion: The Essex-Lopresti spike reduction is a useful method for the treatment of tongue type Sanders type 2C fractures of the calcaneus. Results are better than previous series of intraarticular fractures treated with ORIF.