Session VIII - Foot and Ankle

Management of Complex Intra-Articular Calcaneal Fractures with the Ilizarov External Fixator - Indications and Outcomes

Vladimir Schwartsman, MD, Roman Schwartsman, MD, Anthony B. Serfustini, MD

University of Nevada, Las Vegas, Nevada, USA

Introduction: The management of acute displaced intra-articular calcaneal fractures remains a controversy in today's Orthopaedics. This is due to the lack of correlation between classification systems and outcomes and in part due to the consistently poor outcomes that result from conventional management of complex intra-articular calcaneal fractures. These poor outcomes can be the result of soft tissue necrosis following an otherwise successful ORIF, early or late collapse of an adequately reduced fracture, the inability to adequately reduce and stabilize a comminuted fracture by conventional means and poor functional outcome due to disruption of subtalar joint mechanics. In an effort to address this problem and improve the outcome for complex intra-articular calcaneal fractures, we applied the Ilizarov method and apparatus for the management of these fractures.

Methods and Materials: From August of 1993 to August of 1996, forty-five consecutive patients with fifty-one calcaneal fractures were treated using the Ilizarov method and apparatus. Only patients with Sander's type III and IV fractures were included in the study. All patients were initially evaluated with plain radiographs as well as coronal plane C.T. scans of the calcaneus. The fractures were reduced using a combination of intraoperative calcaneal skeletal traction, manual fracture reduction and percutaneous fracture reduction with a Steinmann pin if needed. The major emphasis of this technique was closed restoration of the calcaneal width, length and height, stabilization with the Ilizarov frame with slight distraction of the ankle and subtalar joints, but not necessarily an anatomic reduction of already destroyed articular surface of the calcaneus. While still maintaining skeletal traction and slight distraction of the ankle and subtalar joints, an Ilizarov frame consisting of two full rings above the ankle and a 5/8 ring around the calcaneus was applied. The fracture was essentially maintained in portable traction for the duration of treatment in the frame. Patients were allowed to weight bear as tolerated the first postoperative day and gradually progressed to full weightbearing for the 8 weeks that they were in the frame. Following frame removal, a short-leg walking cast, with a well- molded arch, was applied for a period of 2 weeks. After cast removal the patients were started on a physical therapy program and gradually allowed to return to work.

Results: Of the 51 fractures that were treated using this method, 43 were available for follow-up. Of these, 27 were Sanders III and 16 were Sanders IV fractures. Our patients ranged in age from 18 to 78 years. Minimum post-operative followup in our series was six months with some up to 43 months. All of the patients returned to modified duty as manual laborers at an average of four months from time on injury. All patients were uniformly satisfied with their outcomes and recorded good to excellent objective results. Functional results were analyzed with Maryland Foot Score. There were no infections, no heel pain and none of the patients required an arthrodesis. Complications were limited to occasional superficial pin tract infections, all of which resolved with more aggressive pin care and oral antibiotics.

Conclusion: The method which we describe proved to be a safe and efficacious means of managing complex intra-articular calcaneal fractures. There were no contraindications for this method. Both subjective and objective outcomes were uniformly good to excellent. We feel that this method offers significant advantages over more conventional means of treating complex calcaneal fractures and would recommend its use for the treatment of all Sanders III and IV type fractures.