Session VII - Foot & Ankle

Open Reduction Internal Fixation and Immediate Subtalar Fusion for Comminuted Intra-articular Calcaneal Fractures: A Review of 33 Cases

Anthony F. Infante, Jr., DO; Keith A. Heier, MD; Bo Lewis, MD; Roy W. Sanders, MD, Florida Orthopaedic Institute, Tampa, FL

Hypothesis: Sanders Type IV intra-articular calcaneal fractures are devastating injuries associated with complications and significant morbidity. Open reduction and internal fixation with immediate subtalar fusion can restore both the calcaneal and hindfoot anatomy, as well as minimize arthritic pain, thereby allowing early return to work.

Materials and Methods: Between 1991 and 1997, 503 displaced intra-articular fractures were treated with open reduction and internal fixation at our level 1 trauma center. Of these 503, 33 were treated with ORIF and immediate subtalar fusion. There were twenty-nine males and four females. The mechanisms of injury included fifteen falls, twelve motor vehicle, one motorcycle and two boating accidents. Sixteen of the patients had other injuries associated with their calcaneal fractures including five talus fractures, seven contralateral calcaneal fractures, two navicular fractures, one cuboid fracture, eight femur fractures, three tibia fractures, five bimalleolar ankle fractures, four spine fractures, four mandibular fractures, four wrist fractures and a pelvis fracture. The decision to fuse the subtalar joint was made pre-operatively in seventeen patients after reviewing the x-rays and CT scans and intra-operatively in thirteen. Twenty-three were closed calcaneal fractures and ten were open. Of the ten open fractures there were 2 Gustilo type I, 1 Gustilo type II and 7 Gustilo type III (4A, 3B, 0C). All ten of the open fractures had irrigation and debridements of the open wounds followed by internal fixation using an extensile lateral approach and subtalar fusion using percutaneous incisions for 6.5-8.0 cancellous cannulated lag screws. Twenty-eight of the thirty subtalar fusions were performed with bone graft (21 autogenous iliac crest and 7 with allograft). Data were collected by utilizing hospital and office chart review, x-ray review and patient follow-up. Creighton-Nebraska, AOFAS, Maryland Foot and SF-36 questionaires were recorded at final follow-up.

Results: Three of the thirty-three patients were lost to follow-up, leaving thirty fractures treated by ORIF and immediate subtalar fusion in thirty patients. Follow-up averaged 38 months (range: 14-85 months). The average age of the patients was forty years (range: 19-61 years). Despite the complexity of comminution intra-articularly and the shape of the soft tissue envelope, 28 of the 30 Sanders type IV calcaneal fractures united and fused within 4 months of the index procedure. The two nonunions required revision fusions uniting within four months of the second surgery. The average scores for the Creighton Nebraska, AOFAS and Maryland foot were 61 points (33-80), 78 points (55-94) and 81 points (66-95), respectively. Ten of the patients had complications, seven of those were patients who developed wound problems. Two healed with wet to dry dressings and oral antibiotics, one with whirlpools and oral antibiotics and the other four developed osteomyelitis which was treated with irrigation and debridements and IV antibiotics.

Two of these infections resolved and two developed uncontrollable osteomyelitis and subsequently had below knee amputations. One was a Grade 3A open fracture and the other a closed fracture-dislocation of the subtalar and talonavicular joints. Two of the patients developed claw-toe deformities and had subsequent surgeries correcting them.

Discussion and Conclusion: Sanders type IV calcaneal fractures are devastating injuries. These injuries occur secondary to high energy trauma usually a fall from a height or a motor vehicle accident. The patients with this type of injury historically have not done well whether ORIF was performed or conservative care chosen. A majority of these end up needing a salvage fusion of the subtalar joint shortly after the patients resume ambulation and activities of daily living. These fusions are much more difficult if conservative care was the primary treatment, since the normal anatomy must be restored first before the joint can be fused. This also causes a problem with soft tissues because the healing process has shortened the skin and soft tissues. Early open reduction and internal fixation in Sanders Type IV fractures treated without immediate fusion is usually followed by a "wait and see" attitude. These patients are usually not able to resume normal function or return to work for approximately six months. Once they try to work or stay on their feet for long periods of time, the pain in the subtalar joint is too great for them to proceed, requiring a salvage fusion and another 6-9 months of rehabilitation. By performing the ORIF and subtalar fusion in one procedure the surgeon can limit the morbidity associated with this fracture. Our final outcomes using the Creighton-Nebraska, Maryland Foot or AOFAS indicate both reasonable outcomes with patients back to work sooner. We believe this is the largest reported series of ORIF with immediate subtalar fusions for comminuted intra-articular calcaneal fractures.