Session II - Foot and Ankle

Small Incision ORIF Displaced Calcaneal Fractures

James B. Carr, MD, Medical College of Virginia, Richmond, VA; Jonathan Scherl, MD, University of Medicine and Dentistry of New Jersey, Camden, NJ

Significance: This study documents the success of small incision open reduction internal fixation (ORIF) in obtaining anatomic reduction for calcaneal fractures. This approach matches the pathoanatomy with the surgical technique. The morbidity and risks of extensile approaches are avoided. This procedure can be performed on an overnight observation basis.

Method: Prospective data collection; single surgeon, Level I trauma center

Patient outcome tool: Maryland Foot Score

Fractures classification used: Sanders, Essex-Lo Presti and OTA.

Materials: Over a thirty-eight month period, thirty displaced, intraarticular calcaneal fractures (twenty-eight patients) were treated with small (max. - ~ 2cm) incisions: six lateral only, twenty-two medial/lateral and two medial only. Twelve of twenty-eight patients had associated skeletal trauma. The approach was chosen based on the primary column displacement. A combination of small/minifragment lag screws and minifragment plates were used for fixation. An arthroscope was used laterally to monitor/document the posterior facet reduction in 25/30 cases. Reductions were radiographically/arthroscopically graded: 0-1mm, 1-2mm and >2mm on the lateral, axial and Broden views.

Results: There were 20 Sanders II (OTA 73-C1), 5 Sanders III (OTA 73-C2), 3 Sanders IV (OTA 73-C3) and 2 (OTA 73-B3) fractures.

Nineteen fractures were classified as joint depression, eleven were tongue type. Posterior facet reductions were graded 0-1mm 17 cases, 1-2mm 9 cases, and >2mm 2 cases. Clinical outcome using the Maryland Foot Score: (one year or greater follow up): average 86, range 77-99, 14/19 feet with an average clinical follow up of 17 months (range 12-34).

Complications: Superficial infection 1, broken screw 1, P. Tibial N. injury (temporary) 1 (minor heel numbness was observed in all cases with medial approach), loss of reduction (minor) 2, deep infection 0, free flaps 0, amputation 0, transient. subtalar fusion 0 (one patient considering at 9 months follow-up).

Discussion/Conclusion: Small incision ORIF, based on addressing the primary column displacement, achieved anatomic reduction comparable to extensile approaches. The key displacements addressed were the superomedial fragment, anterolateral fragment and posterior facet. Clinical results appear to follow the reduction obtained, although, a symptom- free heel was rare. Cosmesis and shoe wear were excellent in all cases.