Late Treatment of Displaced Intra-articular Calcaneus Fractures: When is Late too Late?
Corresponding Author: Michael Swords, Michigan Orthopedic Center, Department of Orthopedic Surgery, Sparrow Hospital, Lansing, Michigan, United States
Multiple studies support open reduction and internal fixation of displaced intra-articular calcaneus fractures (DIACFs). Clinical evidence does not currently support a clear, well-defined treatment recommendation for DIACFs that present in a late fashion. The treatment options for this challenging clinical presentation are reviewed as well as current literature on this most difficult clinical scenario. Specific treatment should be catered to the individual patient with consideration of the technical ability of the surgeon.
How to cite this article: Swords M, Shank J. Late Treatment of Displaced Intra-articular Calcaneus Fractures: When is Late too Late? J Foot Ankle Surg (Asia Pacific) 2022;9(2):67-71.
Source of support: Nil
Conflict of interest: None
Keywords: Calcaneus, Calcaneus fracture, Osteotomies, Subtalar joint, Subtalar arthrodesis, Surgical timing
Calcaneus fractures are rare but account for roughly 60% of tarsal bone fractures.1 The anatomy of the hindfoot is complex, increasing the difficulty of fracture management. The calcaneus is an odd-shaped bone with multiple articular facets and has a very unforgiving soft tissue envelope making appropriate surgical intervention time-sensitive. Certain surgical patterns including beak type, fracture-dislocation, and open fractures of the calcaneus require prompt surgical management.2-4 Surgery, if performed, should ideally be done when the soft tissues have recovered and the fracture fragments are still mobile. The management of calcaneus fracture in delayed presentation requires technical skill and a surgeon experienced with both acute fracture management skills as well as arthrodesis and osteotomy techniques. The goal of operative treatment of displaced intra-articular calcaneus fractures (DIACFs) is to restore calcaneal height, axial alignment, and anatomically reduce the articular surface. This is also true in the management of late presenting fractures, but successfully doing so becomes more and more difficult with time.
Who should Perform Late Surgery for Displaced Intra-articular Calcaneus Fractures?
For acute management of DIACFs, clinical series that include surgeons with low volume have higher complication rates than those reported in series where the surgical care was provided by experienced surgeons who regularly perform many calcaneus fracture surgeries.5 Fractures treated at centers with higher calcaneus fracture volume have fewer surgical complications.6 Complication rates have been observed to decrease by 9% for each additional five surgeries performed by a surgeon for DIACFs annually.7 Late management of calcaneus fractures should ideally be performed by experienced higher volume surgeons with expertise in both acute fracture management as well as available salvage techniques including osteotomy and arthrodesis as these cases are technically more difficult. Results in late management of calcaneus fractures may not be as predictable in surgeons with lesser experience.
In most circumstances, surgical procedures for DIACFs treated by the lateral extensile approach are performed 1-2 weeks after injury. Surgery for DIACFs within 7 days of injury by a lateral extensile approach is associated with higher wound complication rates.8 This time interval allows for resolution of soft tissue swelling following trauma. In more severe injuries this will allow for fracture blisters or fracture-related hematoma to improve. After 2 weeks fibrosis begins to occur along the fracture lines making reduction technically more difficult. Additionally, with the restoration of calcaneal height at the time of reconstruction wound closure may become increasingly difficult as time passes due to contracture of the soft tissue envelope potentially leading to an increased rate of wound healing problems and infection.9,10
Why should Late Surgical Management for Displaced Fractures be Considered?
Surgical management of DIACFs results in improved outcomes in operative cases where the normal Bohler’s angle is recreated and the articular surface reduction is within 2 mm.11,12 Buckley et al. found significantly better results in patients treated surgically who had joint reduction within 2 mm and a higher individual Bohler’s angle.12 Agren and colleagues in a post hoc analysis of their randomized clinical trial observed higher postoperative Bohler’s angle, and articular surface reduction leading to superior results in patients with operative treatment.12,13 A recent long-term evaluation of a large series of calcaneus fractures observed restoration of Bohler’s angle to within 5 degrees of the unaffected side to be a major factor leading to improved function.14 In late management of DIACFs, the goal of operative treatment should be to restore calcaneal height, axial alignment and anatomically reduce the articular surface where possible as this leads to improved function.
Nonoperative management is a poor option for all DIACFs as it is six times as likely to lead to subtalar arthrodesis because of posttraumatic arthritis and pain.11 As a result, in DIACFs nonoperative care should be reserved for individuals with medical comorbidities that would result in an excessive risk of peri-operative complications. Surgical options for late presenting fractures to restore normal alignment of the hindfoot include standard surgical fixation if the fracture lines have not ossified. If fracture consolidation has occurred, treatment options include primary subtalar arthrodesis and osteotomy procedures. Osteotomies may be performed to both reconstruct the calcaneus and spare the subtalar joint or coupled with subtalar arthrodesis.
Small Incision, Percutaneous, and Sinus Tarsi Approaches
Small incision, percutaneous, and sinus tarsi approaches, while gaining in popularity for acute management of fractures, generally do not have a role in the late management of calcaneus fractures. These surgical techniques are performed early when fracture fragments are mobile and amenable to indirect manipulation. As time passes the fracture fragments become less mobile due to fibrosis occurring between fracture fragments. As a result, reduction with percutaneous or sinus tarsi approaches becomes more difficult over time. These smaller incision techniques are best indicated for early fracture fixation when fracture fragments are mobile and easily manipulated with instrumentation.2,15-20
Late ORIF by Lateral Extensile Approach
Swords et al. reported on the results of a series of patients treated for DIACFs beyond 28 days.21 The mean number of days from injury to fixation was 33.4 (range 26-58 days). All fractures were treated with a standard lateral extensile approach allowing for mobilization of fracture fragments after the fracture lines had been cleaned of fibrosis. Thirteen patients (72%) were treated in a delayed manner because of late referral from an outside institution. Two patients (11%) were treated more than 25 days after injury because of hemodynamic instability as a result of polytrauma. Two patients (11%) had significant fracture blisters which prevented earlier surgical treatment. One patient (6%) was treated in a delayed fashion due to sepsis. Bohler’s angle at the time of injury was 10.9, which was corrected to a mean of 33.3 following operative fixation. Bohler’s angle decreased to a mean of 28.1 at the time of the final follow-up. Mean Bohler’s angle was 32.3 on the contralateral uninjured side. The patients in this study had an average MFA score of 16.5 (range 1-34), which is not significantly different from the published data for midfoot injuries, hindfoot injuries, or both, 1 year after injury. (mean = 22.1). There were no subtalar arthrodesis procedures in the follow-up period for this patient population at a mean of 26.1 months (range, 12.5-100 months). MFA results averaged 16.5 (range, 1-34). The authors did note that the surgery was technically difficult and had longer operative times compared to more timely management of DIACFs. Late ORIF is a viable option for the treatment of DIACFs (Fig. 1).
Anatomic Reduction by Osteotomy without Subtalar Arthrodesis
Anatomic reduction is also associated with improved outcomes of late presenting calcaneus fractures, even in those requiring osteotomy to achieve reduction. Rammelt et al. reported on five fractures that presented at an average of 2.9 months after fracture.22 All were treated with joint preserving osteotomy and internal fixation. A second series reported by Rammelt looking at joint preserving osteotomy for the late reconstruction of calcaneus fractures demonstrated that only 1 of 26 patients ultimately required a subtalar arthrodesis within the follow-up period.23 Yu et al. reported on 24 patients with late presentation after calcaneus fractures with the average time from injury to subtalar joint salvage osteotomy of 5.7 months.24 AOFAS scores improved to an average of 85.9 (range, 81.5-90.4). Six patients had wound edge necrosis and two had superficial infection. One patient required a subtalar arthrodesis for arthritis at 2 years. Bohler’s angle, Gissane’s angle, talus declination angle, and width and height of the calcaneus can all be improved to a great extent demonstrating restoration of normal calcaneus morphology (Fig. 2). Arthrodesis procedures should be considered If the articular cartilage is nonviable or does not mobilize with the fracture fragment.
Primary subtalar arthrodesis may be considered in patients with late presentation of calcaneus fractures. Most studies looking at the treatment of calcaneus fractures with primary subtalar arthrodesis have been in patients with highly comminuted fractures (Sanders type IV).14 These injuries are generally associated with worse functional results.25-27 In primary arthrodesis, fracture reduction is followed by removal of articular cartilage, bone grafting, internal fixation to provide stability, and maintain reduction, which is essential to provide the stability necessary for arthrodesis of the subtalar joint, and maintenance of normal hindfoot valgus alignment. If a calcaneus fracture is well reduced and healed and ultimately requires an in situ subtalar arthrodesis due to post-traumatic arthritis the procedure is associated with a better clinical outcome and fewer complications than procedures that combine arthrodesis and osteotomy to correct malunions of the calcaneus that are a result of nonoperative treatment.28,29 Therefore, surgical fixation is favored over conservative treatment and primary arthrodesis for management of calcaneus fractures that present late, when possible. Patients treated with primary arthrodesis with late presentation for DIACFs had marked improvement of the AOFAS hindfoot score from 19 preoperatively at a mean of 81.2 at follow-up of 4.1 years (range, 2-10 years).22
In summary, a variety of treatment options exist for patients that present late after DIACFs. Restoration and maintenance of Bohler’s angle over time are essential for superior results of calcaneus fracture surgery regardless of the timing of surgery. Restoration of calcaneal height, axial alignment of the hindfoot, and articular congruity should be the goals in late treatment. Operative fixation more than 25 days after injury with the restoration of Bohler’s angle did not result in subtalar arthritis requiring arthrodesis at a mean follow-up of 26.1 months. This data suggests that formal ORIF by an extensile lateral approach is a viable and safe treatment option for patients with a displaced calcaneal fracture presenting in a delayed manner, with a low incidence of complications, when performed by an experienced surgeon able to reduce the fracture. In clinical cases that present even later when fracture consolidation has occurred, intra-articular osteotomy without subtalar arthrodesis may be used to restore alignment, achieve anatomical reduction, and improve function.24 Osteotomy to improve alignment and shape of the calcaneus coupled with subtalar arthrodesis is an additional surgical option when the articular surface is nonviable and cannot be restored. Primary subtalar arthrodesis should generally be reserved for late sequelae of calcaneus fractures. Management strategies for malunion of calcaneus fractures are beyond the scope of this manuscript but have been well described and include a series of subtalar arthrodesis, bone block arthrodesis, calcaneal osteotomy couple with subtalar arthrodesis.30-36 A firm understanding of the malunion types and treatment strategies is certainly of value to the acute management of DIACFs. All operative strategies without arthrodesis are performed to prevent the long-term morbidity that occurs from malunion of these difficult fractures while retaining the subtalar joint motion necessary for improved function.37
Delayed presentation of displaced intra-articular calcaneus fracture is challenging and should be operated upon by an experienced surgeon. The extensile lateral approach is the preferred approach and management options like delayed ORIF, osteotomy, and or arthrodesis should be carefully selected.
Michael Swords https://orcid.org/0000-0003-0839-8896
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