CalcanealCalcaneal FracturesFracturesDr. Dr. LachowskiLachowskiDr. Dr. GharsaaGharsaa

AnatomyAnatomyXX--raysraysClassificationsClassificationsTreatment Options & ApproachesTreatment Options & ApproachesComplicationsComplicationsWhat people sayWhat people say

AnatomyAnatomy

•• SubtalarSubtalar jointjoint── Facets: anterior, middle, posteriorFacets: anterior, middle, posterior

•• CalcaneocuboidCalcaneocuboid jointjoint•• SustentaculumSustentaculum•• TuberosityTuberosity•• Anterior processAnterior process

Anatomy: Anatomy:

Facets of Facets of ST JointST Joint

Ant.Ant.

MiddleMiddle

Post.Post.

Tub.Tub.

IO IO liglig..

Anatomy: Anatomy:

BonyBony

SustentaculumSustentaculum

Medial

Lateral

Ant. Ant. processprocess

TuberosityTuberosity

Sinus tarsiSinus tarsi

Imaging: Plain FilmsImaging: Plain Films

Standard ViewsStandard Views•• 1. Lateral1. Lateral•• 2. 2. BrodenBroden’’ss•• 3. Axial3. Axial

1.1.

3.3.2.2.

BrodenBroden’’ss View View

• Posterior facet

• Positioning

A. 20° IR view (mortise)

B. 10°-40° plantar flex.

Lateral View Lateral View

BohlerBohler’’ssAngleAngle GissaneGissane’’ss

AngleAngle

ClassificationsClassifications

•• Several usedSeveral used-- None are idealNone are ideal•• Most commonly usedMost commonly used

── EssexEssex--LoprestiLopresti── SandersSanders

ESSEXESSEX--LOPRESTI LOPRESTI ClassificationClassification

•• HistoricalHistorical•• BasicBasic

1. Joint depression type2. Tongue type

1.

2.

SandersSandersClassificationClassification

•• Based on CT findingsBased on CT findings•• # joint fragments# joint fragments

•• 2 = type II2 = type II•• 3 = type III3 = type III•• 4 or more = type IV4 or more = type IV

•• Predictive of resultsPredictive of results

Operative vs. NonOperative vs. Non--op Treatmentop Treatment

•• Orthopedic literature is lacking Orthopedic literature is lacking •• NoNo prospective, randomized studies with prospective, randomized studies with

longlong--termterm followfollow--upup

Treatment: Treatment: A Rational Approach?A Rational Approach?

•• Many treatment methods attemptedMany treatment methods attempted•• ““BestBest”” method remains controversialmethod remains controversial•• Assess each case individuallyAssess each case individually

Injury/ patient/ surgeonInjury/ patient/ surgeonRisks vs. benefits Risks vs. benefits

Operative Treatment: Operative Treatment: RationaleRationale

•• Restore anatomyRestore anatomy── Shape and alignment of Shape and alignment of hindfoothindfoot── Articular congruencyArticular congruency

•• Return to function & prevent arthritisReturn to function & prevent arthritis•• Typically, restoring articular anatomy gives Typically, restoring articular anatomy gives

improved results improved results ifif complications are complications are avoidedavoided

Operative Treatment Operative Treatment OptionsOptions

•• ORIFORIF•• Closed Reduction/ Int. FixationClosed Reduction/ Int. Fixation── Percutaneous Percutaneous ── Arthroscopic assistedArthroscopic assisted

•• IlizarovIlizarov•• Primary FusionPrimary Fusion

ORIF: Lateral ApproachORIF: Lateral Approach

•• Lateral decubitusLateral decubitus •• ““LL”” incisionincision

ORIF: Lateral ApproachORIF: Lateral Approach

•• ““No touchNo touch””techniquetechnique

• Lateral wall Lateral wall removedremoved

ORIF: Lateral ApproachORIF: Lateral Approach

• Schanz pin to manipulate tuberosity

• Clean out fracture

• Disimpactsustentacularfragment

ORIF: Lateral ApproachORIF: Lateral Approach

•• Bone graft?Bone graft?•• Replace lateral wall Replace lateral wall •• Apply plateApply plate•• Recheck radiographsRecheck radiographs

perimeter plate

ComplicationsComplications

OperativeOperativeMalunionMalunionStiffnessStiffnessSubtalarSubtalar arthritisarthritisPeroneal tendonsPeroneal tendonsSural nerve painSural nerve painHeel pad problemsHeel pad problems

NonNon--operativeoperativeMalunionMalunionVarus Varus hindfoothindfootShortened foot = short Shortened foot = short lever armlever armPeroneal impingement/ Peroneal impingement/ dislocationdislocationShoewearShoewear problemsproblemsStiffness, Stiffness, arthritis(STarthritis(ST))

Operative Treatment: Operative Treatment: ComplicationsComplications

Wound problemsWound problems•• Apical wound necrosisApical wound necrosis

Stop ROMStop ROMLeave sutures inLeave sutures in

•• InfectionInfectionAntibioticsAntibioticsI&DI&DSoft tissue coverage?Soft tissue coverage?

What people say?What people say?

Displaced IntraDisplaced Intra--Articular Articular CalcanealCalcaneal FracturesFractures

Effect of operative treatment compared with Effect of operative treatment compared with nonoperative treatment on rate of union, complications, nonoperative treatment on rate of union, complications, and functional outcome after intraand functional outcome after intra--articular articular calcanealcalcaneal # #

Among 20 relevant articles:Among 20 relevant articles:4 RCTs: 4 RCTs:

O'Farrell 1993O'Farrell 1993ParmarParmar 19931993ThordarsonThordarson 19961996Buckley 2002Buckley 2002

2 systematic reviews2 systematic reviewsRandle 2000Randle 2000Bridgman 2000Bridgman 2000

1 abstract of economic analysis study1 abstract of economic analysis studyBrauerBrauer 2004 OTA Meeting2004 OTA Meeting

Bajammal et al, JOT 2005Bajammal et al, JOT 2005

ConclusionConclusion

Evidence from RCTs with methodological Evidence from RCTs with methodological limitations revealed:limitations revealed:

No significant difference in pain and functional No significant difference in pain and functional outcome between the two groupsoutcome between the two groups

Operative treatment maybe superior to Operative treatment maybe superior to nonoperative treatment concerning return to nonoperative treatment concerning return to work and the ability to wear the same shoeswork and the ability to wear the same shoes

ConclusionConclusionBased on postBased on post--hoc subgroup analyses, hoc subgroup analyses, hypotheses include:hypotheses include:a.a. Potential benefit of operative treatment in Potential benefit of operative treatment in

womenwomennot WSIB,not WSIB,younger malesyounger maleshigher higher BBööhlerhler angleanglelight workloadlight workloadsingle, simple displaced intrasingle, simple displaced intra--articular fracture.articular fracture.

b.b. Potential benefit of nonoperative treatment in:Potential benefit of nonoperative treatment in:50 years or older50 years or oldermalesmalesWSIBWSIBheavy workloadheavy workload

(Buckley et al, 2002 JBJSA),(Buckley et al, 2002 JBJSA),

ConclusionConclusion

Arthrodesis rates are significantly reduced Arthrodesis rates are significantly reduced with operative treatment compared with with operative treatment compared with nonoperative treatmentnonoperative treatment

From societal perspective, operative From societal perspective, operative management is less costly and more effective management is less costly and more effective than nonoperative carethan nonoperative care

Displaced IntraDisplaced Intra--articular articular CalcanealCalcaneal Fractures:Fractures:Variables Predicting Late Variables Predicting Late SubtalarSubtalar FusionFusion

Amount of initial injury involved with the Amount of initial injury involved with the calcanealcalcaneal # is the 1ry prognostic # is the 1ry prognostic determinant of longdeterminant of long--term patient outcometerm patient outcome

A distinct patient group with a displaced intraA distinct patient group with a displaced intra--articular articular calcanealcalcaneal who are at who are at high risk of high risk of subtalarsubtalar fusion, These include:fusion, These include:Male Male WSIB (3 times)WSIB (3 times)Heavy labor work Heavy labor work BBööhlerhler angle less than 0angle less than 0°° (10 times) (10 times) SandersSanders--type IV type IV calcanealcalcaneal fractures (5.5 times )fractures (5.5 times )Initial treatment was nonoperative (6 times) Initial treatment was nonoperative (6 times)

Initial ORIF of patients with displaced intraInitial ORIF of patients with displaced intra--articular articular calcanealcalcaneal # minimized # minimized the likelihood that the likelihood that subtalarsubtalar fusion would be required. fusion would be required.

CsizyCsizy, Marcel; Buckley, Richard, Marcel; Buckley, Richard

Bilateral Bilateral calcanealcalcaneal fracturesfracturesOperative versus nonoperative treatmentOperative versus nonoperative treatment

Pts sustaining bilateral Pts sustaining bilateral calcanealcalcaneal # are very similar to # are very similar to those in whom the injury is confined to one side. those in whom the injury is confined to one side.

Neither objective nor subjective functional outcomes are Neither objective nor subjective functional outcomes are significantly improved following operative intervention.significantly improved following operative intervention.

However,careful operative pt selection will minimize However,careful operative pt selection will minimize complications and lessen need for late complications and lessen need for late subtalarsubtalararthrodesis.arthrodesis.

Dr. R. BuckleyDr. R. Buckley

SummarySummary

•• High energy injuriesHigh energy injuries•• Risk for long term morbidityRisk for long term morbidity•• ORIF can give good, reproducible results ORIF can give good, reproducible results ifif

complications are avoidedcomplications are avoided•• Individualize treatment Individualize treatment •• LongLong--term outcomes studies are needed term outcomes studies are needed

comparing treatment alternativescomparing treatment alternatives