SLR - December 2017 - Catlea M. Gorman
Medial External Fixation for Staged Treatment of Closed Calcaneus Fractures: Surgical Technique and Case Series
Reference: Githens M, Shatsky J, Agel J, Bransford RJ, Benirschke SK. Medial External Fixation for Staged Treatment of Closed Calcaneus Fractures: Surgical Technique and Case Series. J Orthop Surg 2017; 25(3):1–8.
Scientific Literature Review
Reviewed By: Catlea M. Gorman, DPM
Residency Program: Regions Hospital/HealthPartners Institute for Education and Research, St. Paul, MN
Podiatric Relevance: Soft-tissue damage that occurs during calcaneal fractures often dictates the timing of definitive fixation. Delaying surgical intervention results in retensioning of the contracted soft-tissue envelope during surgery, which could contribute to postoperative wound complications. The authors have proposed a two-stage approach for closed, severely displaced joint depression or tongue-type fractures. The first stage involves early medial delta frame application to restore normal calcaneal height, length, width and coronal plane alignment. The second stage involves a lateral extensile approach for definitive reduction and fixation. The technique for application of the medial external fixator is described as well as the results of 20 patients treated with this approach.
Methods: The technique involved first placing a pin from the medial cuneiform into the body of the lateral cuneiform. A tibial pin was placed bicortically about one centimeter proximal to the level of the incisura and parallel to the tibial plafond. The medial calcaneal pin was placed in the posterior tuberosity with care taken to not penetrate the lateral cortex. When placing the bar between the tibial and calcaneal pins, valgus moment was used to reduce any varus deformity. A compressor-distractor was also used to restore height. All procedures were performed by a single surgeon. Inclusion criteria included closed fractures that had joint depression, tongue-type or comminuted fractures that were not amenable to percutaneous reduction, a Bohler’s angle less than five degrees and/or fractures with severe blistering. Bohler’s angle was assessed before and after closed reduction with the external fixator. All patients remained nonweightbearing for three months.
Results: Twenty-one fractures in 20 patients met the inclusion criteria. Mean follow-up was 15 months. Average time from injury to application of external fixation was 2.8 days and average time from external fixation application to definitive fixation was 11 days. Bohler’s angle improved from an average of two degrees preop to 22 degrees following external fixation. Three out of twenty-one patients developed complications postoperatively. One developed a pin tract infection, which resolved with oral antibiotics. One patient developed a DVT, which was treated with Coumadin, and the other patient developed a nonunion, which went on to subtalar joint fusion.
Conclusions: Staged approach to closed calcaneal fractures is a way to provide early reduction and to limit the risk of wound healing complications. This was previously reported using a two-pin technique; however, the authors describe a modified technique to allow for multiplanar correction. Despite multiplanar correction, it was determined that external fixation alone cannot adequately restore Bohler’s angle. Ligamentotaxis through external fixation does not correct for any depressed posterior facet fragments, making ORIF necessary to fully correct Bohler’s angle. While none of the patients developed any deep infection postoperatively, this study did not have a comparison group that would allow them to determine if staged management with external fixation reduced rates of postoperative wound-related complications compared to a delayed single-stage approach.