SLR - April 2015 - Irina Bazarov

Operative Treatment of Displaced Intraarticular Calcaneal Fractures: Long-Term (10-20 Years) Results in 108 Fractures Using a Prognostic CT Classification

Reference: Sanders R, Vaupel ZM, Erdogan M, Downes K. Operative Treatment of Displaced Intraarticular Calcaneal Fractures: Long-Term (10-20 Years) Results in 108 Fractures Using a Prognostic CT Classification. J Orthop Trauma. 2014 Oct;28(10): 551-63.

Scientific Literature Review

Reviewed By: Irina Bazarov, DPM
Residency Program: Kaiser San Francisco Bay Area Foot and Ankle: Oakland CA

Podiatric Relevance: Treatment of displaced intraarticular calcaneal fractures represents a challenging dilemma for podiatric surgeons. Sanders prognostic classification system, introduced in 1992, has offered a valuable approach to evaluation and treatment, as well as outcome stratification based on the analysis of coronal and axial injury CT scans. The present article confirms the prognostic value of Sanders classification system in Sanders type II/III fractures, while calling into question the benefits of locking plates and bone graft in maintaining fracture reduction.
Methods: A retrospective evaluation of radiographic and clinical data of the patients with closed displaced intraarticular calcaneal fracture of Sanders type II or III treated with open reduction and internal fixation with lag screws and non-locking plate by the senior author (R.S.) between January 1, 1990 and December 31, 2000, was performed. Of the 638 patients identified, 208 met inclusion criteria, and 93 (108 fractures) were available for follow up. The quality of initial reduction, its maintenance, and grade of post-traumatic arthritis were assessed using CT scans and plain radiographs. Analysis of postoperative ankle joint range of motion and gait abnormalities was performed. SF-36, AOFAS ankle-hindfoot score, Maryland Foot Score, Ankle Osteoarthritis Score (AOS), and Visual Analogue Scale (VAS) were used for functional outcome assessment. Fisher exact and chi-squared test were used for group comparisons.

Results: Of 108 fractures, 70 (65 percent) were Sanders type II and 38 (35 percent) Sanders type III. All fractures had restoration of Bohler and Gissane angles based on immediate postop films, and 95.4% fractures had anatomic reduction of posterior facet based on immediate postop CT. At the final follow up, reduction was maintained in 97 percent of fractures. Subtalar joint arthritis requiring arthrodesis occurred in 31 fractures (29 percent), which were categorized as absolute failures. Of these fractures, 13 were Sanders type II (18.6 percent of type II fractures) and 18 were Sanders type III (47.4 percent of type III fractures), suggesting that type III fractures were 4 times more likely to necessitate fusion than type II fractures. Average functional outcome scores were above national averages, with SF-36 PCS being 46.2, SF-36 MCS being 54.2, AOFAS AHS 75, AOS-D 25.3, Maryland Foot Score 80, and VAS 1.75. Radiographic assessment at final follow up has demonstrated that severe posttraumatic arthritis was 6.5 times more likely to develop in type III fractures than in type II fractures. Among subtypes, presence of C-line in a type III fracture was associated with worse outcome. Lateral wall irritation in shoe gear necessitating implant removal was the most common complication (50 percent of fractures). Other complications included lateral gutter scarring, recurrent peroneal tendon pain and subluxation, and apical wound necrosis.

Conclusions: The article has demonstrated that Sanders classification remains prognostic for type II and III displaced intraarticular calcaneal fractures after long term follow up (up to 20 years). Additionally, the authors have shown that their technique emphasizing anatomic articular reduction, with exposure through a lateral extensile approach, and use of nonlocking plate and lag screws, without bone graft or locking plate, leads to successful long-term functional and radiographic outcomes. The main strength of this work lies in validation of widely utilized Sanders classification system over a long term follow up. Among the potential limitations of the article, is the authors’ failure to reach out to all of the patients who met the inclusion criteria at the final follow up, thus introducing a potential bias. 

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