SLR - May 2010 - Seth M. Felice

Subtalar Fusion After Displaced Intra-Articular Calcaneal Fractures: Does Initial Operative Treatment Matter?

Radnay, C., Clare, M., Sanders, R., (2009).  Subtalar Fusion After Displaced Intra-Articular Calcaneal Fractures: Does Initial Operative Treatment Matter? Journal of Bone and Joint Surgery (American), 91, 541-546.

Scientific Literature Reviews

Reviewed by:  Seth M. Felice, DPM
Residency Program: St. John Hospital and Medical Center, Detroit, MI

Podiatric Relevance:
"The man who breaks his heel bone is done" -Cotton, 1916
Nearly 100 years since that famous proclamation, intra-articular calcaneal fractures continue to represent a formidable reconstructive challenge for even the most experienced foot and ankle surgeons. A subtalar joint arthrodesis in calcaneal fracture patients is often necessitated at a later date due to the painful arthritic changes or malunion. Thus, the question arises: are the risks and demands of an initial calcaneal ORIF justified when the STJ may require a fusion down the line regardless? Evidence is provided by a highly accomplished trauma surgeon who has performed over 600 acute calcaneal ORIF procedures.

Seventy five consecutive STJ fusions for treatment of post-traumatic arthrosis of the STJ following displaced intra-articular calcaneal fractures were performed by the senior author (R.W.S.) over a 13 year period. This sample size was statistically determined to have at least 80% power. Group A consisted of 36 fractures which had been managed with initial ORIF by the senior author, and an in situ STJ arthrodesis was performed utilizing joint resection, cancellous allograft chips, and cannulated lag screws. Any additional post-traumatic STJ arthrodesis procedures following initial calcaneal ORIF were excluded from the study if the standardized initial fixation had not performed by the senior author. Group B consisted of 39 fractures which had initially received nonoperative care at another insitution or had reached fracture consolidation prior to arrival at the senior author's institution, and realignment STJ arthrodesis was performed by the senior author utilizing structural autograft or allograft, lag screw fixation, and calcaneal osteotomy as was necessary to correct the malunion. The treatment groups were evaluated at a minimum of 48 months after STJ fusion by a research nurse who was blinded to the initial treatment and purpose of the study, and the outcome analyses utilized were the Maryland Foot Score and the AOFAS ankle-hindfoot score.

A 100% follow up rate was achieved, and the average patient follow up period was 62.5 months in Group A (initial ORIF) and 63.5 months for Group B (initial nonoperative care). Group A contained a higher percentage (67% versus 44%, p=0.06) of Workers' Compensation claim patients. Group A patients received STJ arthrodesis an average of 22.6 months after initial ORIF, and group B received fusion an average of 16.4 months after injury. Initial union rate of 92% for each group was reached, and solid union was accomplished in all other cases with a revisional arthrodesis procedure. Delayed wound healing (11% versus 28%, p=0.08) and prolonged antibiotic use greater than six weeks (6% versus 28%, p=0.01) were noted to be less frequent in Group A. Most notably, Group A demonstrated superior averaged results in both the Maryland Foot Score (90.8 versus 79.1, p<0.0001) and AOFAS ankle-hindfoot score (87.1 versus 73.8, p<0.0001).

The current body of medical evidence regarding initial treatment for severe calcaneal fractures fails to offer clear consensus. This summarized Level III study was well designed with sufficient power and a blinded evaluator, and it did not receive external funding. Thus, we are offered the outcome results from a highly experienced orthopedic trauma surgeon regarding STJ arthrodesis for treatment of arthritis or malunion following displaced intra-articular calcaneal fracture. Initial ORIF of such fractures appears advisable if a specialist surgeon is available to attempt anatomic realignment of the calcaneus shape and STJ congruity. Based on the study results, the benefits of initial calcaneal ORIF when compared to initial nonoperative treatment include less technically demanding procedure if subsequent STJ fusion is needed, fewer wound complications, and significantly better clinical and functional outcomes.

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