SLR - May 2020 - Abimbola O. Johnson

Late Treatment of Displaced Intra-Articular Calcaneus Fractures: Successful Management with Anatomic Reduction

Reference: Swords, M, Shank J, Fraticelli N, Benirschke S. Late Treatment of Displaced Intra-Articular Calcaneus Fractures Successful Management with Anatomic Reduction. J Orthop Trauma. 2020 Feb; 34(1):21-25

Scientific Literature Review 

Reviewed By: Abimbola O. Johnson, DPM
Residency Program: Regions Hospital/HealthPartners Institute – St. Paul, MN

Podiatric Relevance: Management of displaced intra-articular calcaneal fractures greater than two weeks often presents with increased complications due to difficulty reducing fracture fragments, soft tissue contraction, and increased wound healing problems. This study proposes that open reduction internal fixation of displaced, intra-articular calcaneal fractures is a viable surgical option for fractures older than one month.

Methods: This is a level IV, retrospective case series which took place from 1994 to 2002. 20 patients were treated with ORIF for a displaced, intra-articular calcaneus fracture more than 25 days after injury. Eleven patients were men and seven were women. The average patient age was 39.8 years (27–59). The authors used the OTA/AO classification of 82-B (tongue type) and 82-C (joint depression) fracture types for study inclusion. All surgeries that were performed included a lateral extensile incision. They comparatively measured Bohler angle pre-operatively, after operative fixation, and at final follow up. They also compared Bohler angle measurement of the injured limb at final follow up with the contralateral limb. The authors used the Musculoskeletal Function Assessment, which was completed over the phone, to evaluate patient functional outcomes. 

Results: All 20 patients achieved radiographic union at final follow up. Eighteen patients completed the MFA with a mean score of score of 16.5 (range, 1–34). The Bohler angle improved an average of 10.9 degrees from pre-operative films to 33.3 degrees on immediate post-operative films. At the final follow up the Bohler angle did reduce to an average of 28.1 degrees, which was within 5 degrees of the average uninjured contralateral foot. There were no cases of postoperative infection or wound complications. Eight patients required hardware removal. There were three secondary operative procedures in the follow-up period including one claw toe procedure, one ankle cheilectomy with tendo-achilles lengthening, and one gastrocnemius slide with osteotomy of the calcaneal tuberosity for malunion. There were no subtalar arthrodesis procedures in the follow up period at a mean of 26.1 months (12.5–100 months). 

Conclusions: The study concluded that ORIF by a lateral extensile approach is a safe and viable option for patients presenting with a delayed displaced intraarticular calcaneus fracture. There was significant improvement in the Bohler angle post-operatively, as well as acceptable functional outcomes, and overall low complication rates. Surgical management of calcaneus fracture is technically demanding and results improve with surgeon experience. The surgeries for this study were performed by a high-volume surgeon at a major trauma center, and their results may not be reproducible by surgeons who are not as experienced. However, this procedure provides a viable surgical option for delayed intra-articular, displaced calcaneus fractures with good functional outcomes.  

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