Session VII - Foot & Ankle

Closed Reduction and Percutaneous Pinning for Comminuted Intra-articular Fractures of the Calcaneus: Preliminary Results

Bruce Ziran, MD; Patrick Bosch, MD, University of Pittsburgh Medical Center, Pittsburgh, PA

Introduction: Treatment goals for fractures of the calcaneus are to restore calcaneal pitch, width, and varus/valgus alignment, as well as reduce the articular surface. Although the correlation between articular reduction and outcome is not as strong as that between injury type and outcome, the current trend in the literature remains operative intervention for these fractures. Unfortunately, complications associated with open reduction are relatively common and in recent studies occurred at a rate of 15-30%. This may be especially true in severe Sanders 3 or 4 fractures. Closed reduction and percutaneous pinning in its various forms has been advocated only for specific types of fractures such as the tongue-type pattern of Essex-Lopressti. Recently, results of a multi-centered prospective trial suggested that the differences between ORIF and closed treatment might be less than previously thought. If the articular reduction might be less important than restoration of hindfoot architecture, then restoring bony alignment without formal ORIF may avoid the complications of ORIF, while also accomplishing many of the treatment goals. The present report describes our preliminary experience with a specific technique of closed reduction and percutaneous pinning in a consecutive series of severe Sanders 3 and 4 calcaneus fractures.

Methods and Materials: Twenty-eight comminuted displaced intra-articular fractures (Sanders 3 and 4) of the calcaneus in 23 patients presenting to a level I trauma center in a three-year period underwent closed manipulation with percutaneous pinning by a single surgeon using the technique described below. After fixation, patients were splinted and then braced with a posterior relief AFO that allowed ankle motion. Pin care was done 3 times a day. They remained non-weight-bearing for 12 weeks, at which point the pins were taken out in the office and weight bearing was initiated. Each patient was given a silicone, based gel pad shoe insert to cushion the heel during the early weight-bearing period. Patients were evaluated at 2,6,12,24,48 weeks and then yearly. In addition to demographic data, associated injuries, radiographic, clinical and functional outcomes were evaluated. Bohlers angle, Gissanes angle, width, varus valgus alignment, and arthrosis were determined. Clinical evaluation examined walking ability, functional status, subtalar motion, and hindfoot problems common to calcaneal fractures (peroneal irritation, heel pain, etc), shoe wear, and patient satisfaction.

Technique: The patient is in the lateral position and manual compression across the calcaneus is applied to reduce width. A large threaded Steinman pin is placed across the calcaneus as posterior and cephalad as possible. A traction bow is place on the pin and longitudinal traction is applied while an assistant stabilizes the leg. A significant valgus reduction maneuver is performed via the traction bow and Steinman pin. A 1/8- or 3/16-inch threaded pin is then placed from the posterior/inferior corner of the calcaneus across the posterior facet and into the talar body. This pin stabilizes the valgus reduction, which is then checked with a calcaneal axial view, using image intensifier. If the alignment is considered satisfactory, a second pin is placed from the posterior calcaneus toward the cuboid. This pin must be felt to enter the cuboid and verified fluoroscopically, since placement medial to the cuboid risks injury to the lateral plantar nerve and short flexors. There is no attempt to reduce the subtalar joint. The pins are cut outside the skin and a splint is applied after verifying reduction and fixation.

Results: Of 23 patients, 21 patients with 25 fractures were available for review with an average follow-up of 11 months (5-20). There were 13 males and 8 females with an average age of 34 years (17-68). There were 9 left, 9 right, and 5 bilateral injuries. The mechanism of injury was a MVA in 7 patients, and a fall in 14 patients. Twelve patients had additional injuries typical of the poly-traumatized patient and 7 had ipsilateral foot/ankle injuries. All patients had acute closed reduction and pinning within 5 days of injury. There were 3 open fractures (1 Gd III and 2 Gd I). All fractures were healed by 3 months. There was one case of compartment syndrome and no infections. At the time of latest follow up, all patients had radiographic signs of subtalar arthrosis. Because of this, Gissanes angle could not be measured. The supplement of Bohlers angle averaged 164 degrees (123-175). The varus/valgus of the calcaneus on the axial view averaged 3.5 degrees varus (range 15 varus to 13 valgus). Subtalar motion was less than ten degrees in all patients. Twelve patients reported minimal to no pain with full activity. These patients were wearing normal shoes and had no limp. These patients were all satisfied with their present condition and felt they had an excellent result. Seven patients had moderate discomfort with full activity, were wearing normal shoes with inserts, and had no limp. Two of these seven patients had peroneal tendonitis from a bulge of the lateral wall of the calcaneous, and improved completely after synovectomy and chielectomy. Two patients had severe pain with activity and had difficulties with shoe wear. They both had a shortened hindfoot with 15 degrees of varus of their calcaneus. They await reconstructive procedures. Thus far, none of the patients have had a subtalar fusion.

Discussion: Recent standards advocate ORIF as the treatment of choice for most calcaneous fractures, but the complication rate remains significant. Even with ORIF not all patients have good to excellent results and the outcome seems to be more related to the initial injury pattern as well as the surgeon's experience. A recent multi-center, prospective randomized study demonstrated at best, only moderate differences between ORIF and splinting alone. Other studies have found moderate correlations between the restoration of articular congruity and outcome. If the articular restoration is not as important as once thought, other factors may play a more important role in outcome. Restoration of calcaneal pitch, varus/valgus alignment and width may be more influential than previously thought. In our series, despite the lack of articular reconstruction, the patients whose hindfoot alignment was restored appeared to experience a good result. Poor results were associated with a shortened hindfoot varus malalignment. As our preliminary outcomes are promising, it may be that restoration of hindfoot alignment without an articular reconstruction may be an attractive alternative or compromise between formal ORIF and simple splinting in situ. The technique is relatively simple, restores hindfoot alignment satisfactorily and with few complications. Further study on this injury and treatment options is warranted.