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Calcaneal fracture fixation- Extended lateral approach and locking plate fixation

    Overview

    Learn the Calcaneal fracture fixation: Extended lateral approach and locking plate fixation surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Calcaneal fracture fixation: Extended lateral approach and locking plate fixation surgical procedure.
    It is without question the case in orthopaedic trauma optimal outcome is closely associated with as near restoration of normal anatomy as possible as a starting point. That said when pursuing this worthy objective, it is of equal importance to :
    A. Appreciate when reconstruction is not going to be attainable due to the nature of the primary injury
    B.Identify when other extraneous factors are going to have a significant enough detrimental effect on your best endeavours to negate them. With calcaneal fractures smoking, non-compliance or inadequate vascular inflow being good examples.
    C.Be realistic about your own limitations as a Surgeon, when dealing with rarer bony injuries, not only in terms of performing the surgery but also in advising patients what is or is not in their best interest.
    Of those patients I’m aware of who do well (or very well) after displaced calcaneal fractures all have their anatomy restored to as near normal as possible. There are fracture patterns of course which will preclude this and the state of the soft tissues/timing of surgery and approach used are also key factors to consider.
    I do not think there can be much argument that calcaneal malunion, especially significant malunion, has predictably detrimental effects upon mechanics of the subtalar joint, and on occasion also the ankle joint. This results in significant mechanical pain and disability, even without considering articular pain and arthritis. The primary cause of such calcaneal malunion is of course the calcaneal fracture, for arguments sake an unavoidable event. The secondary cause of calcaneal malunion however is not treating these injuries surgically, when it is appropriate to do so, which can be regarded as an avoidable event.
    Complications can be significant but should be regarded, and counselled about, proportionately.
    Readers will also find the following OrthOracle operatives techniques of interest:
    Open reduction and internal fixation of calcaneal fracture with extended lateral approach and ZimmerBiomet ALPS plate
    Percutaneous fixation of Tongue-type calcaneal fracture
    Calcaneal fracture fixation : Internal fixation of sustentaculum tali fracture (Acutrak screws)

    Indications

    INDICATIONS
    It is without question the case in orthopaedic trauma optimal outcome is closely associated with as near restoration of normal anatomy as possible as a starting point. That said when pursuing this worthy objective, it is of equal importance to :
    A. Appreciate when reconstruction is not going to be attainable due to the nature of the primary injury
    B.Identify when other extraneous factors are going to have a significant enough detrimental effect on your best endeavors to negate them. With calcaneal fractures smoking, non-compliance or inadequate vascular inflow being good examples).
    C.Be realistic about your own limitations as a Surgeon, when dealing with rarer bony injuries, not only in terms of performing the surgery but also in advising patients what is or is not in their best interest.
    I do not think there can be much argument that calcaneal malunion, especially significant malunion, has predictably detrimental effects upon mechanics of the subtalar joint, and on occasion also the ankle joint. This results in significant mechanical pain and disability, even without considering articular pain and arthritis. The primary cause of such calcaneal malunion is of course the calcaneal fracture, for arguments sake an unavoidable event. The secondary cause of calcaneal malunion however is not treating these injuries surgically, when it is appropriate to do so, which can be regarded as an avoidable event. Some make a valid argument for fixation of displaced calcaneal fractures, based upon the premise that at least if fusion is subsequently required at least the anatomy will allow a straight forward in-situ fusion with normal alignment. Even before that point is reached though, reconstructing displaced intra and periarticular anatomy to as near normal as possible gives the patient some chance of meaningful function, as opposed to no chance at all.
    Of those patients I’m aware of who do well (or very well) after displaced calcaneal fractures all have their anatomy restored to as near normal as possible. There are fracture patterns of course which will preclude this and the state of the soft tissues/timing of surgery and approach used are also key factors to consider.
    The state of the soft tissue envelope is key to timing any open surgery. Fracture blisters and significant swelling develop rapidly and should be permitted to settle fully before any further surgical trauma to the soft tissue envelope occurs. This may require inpatient management with pressurised and temperature reducing compression therapy. Wound breakdown is a reality in most reported series and the end point in the worst cases can be either the need for a free-flap to close the defect or amputation in cases of intractable deep infection, though this is a significant rarity. Calcaneal fractures can be operated upon as late as 2-3 weeks post injury if required, but at the top end of this timescale the fracture lines will need to be carefully recreated as bone healing will be well under way.
    SYMPTOMS & EXAMINATION
    These are invariably injuries caused by a fall from a height, but that height can be surprisingly low, especially in osteoporotic bone. The history is key and patients should undergo a thorough musculoskeletal assessment, especially if a significant fall has occurred. There are a cohort of patients with this injury who have jumped significant heights voluntarily, either because the absence of such a drastic action would have led to worse consequences or in fact who had been hoping for far worse and probably fatal consequences. The circumstances surrounding the injury should be carefully sought and vulnerable patients treated with multidisciplinary input where required.
    A really key assessment to be made is the state of the local soft tissue envelope. Significant swelling often occurs after these injuries and surgery should be absolutely be delayed until the acute swelling, and ideally fracture blisters, have all settled. This may be of the order of 2 weeks or slightly more. The calcaneus is a bone that heals rapidly, being mainly cancellous in nature, so a Surgeon should be prepared to take down a partly united fracture on occasion, having carefully studied the location of the original fracture lines from the CT. These may be only poorly evident initially to inspection at operation.
    A rare complication of a calcaneal fracture is a compartment syndrome of the foot so pain that is unresponsive to standard analgesics should alert the Surgeon to the possibility.
    IMAGING
    Plain X-ray and fracture anatomy
    The main 2 fracture patterns, which can be diagnosed from plain lateral X-Ray are the Tongue-type and the Joint-depression-type. In the former the fracture line exits through the most posterior part of the calcaneus, in the latter it exits inferiorly, immediately behind the posterior facet. An example of each sits at the start of the operative technique. The fracture anatomy common to both is a primary fracture line that splits the posterior facet, separating a medial sustentacular fragment from a larger lateral fragment. This large lateral fragment may be further split by a secondary fracture into a lateral joint fragment (posterior facet) and a body fragment. It is this lateral aspect of the fracture that is the basis of the lateral wall classification.
    The Atkins classification
    Roger Atkins classification of the fracture anatomy, specifically relating to the “lateral wall” of the calcaneus which is the aspect that first presents itself to the Surgeon approaching by a lateral approach, is very useful and much under utilised. It is based on the coronal CT fracture pattern and if used helps understand how to effectively dis-impact then reassemble the fracture. This detail is all comprehensively covered in part 1 of the 2 key papers by Atkins et al, referenced and linked to below.
    Type 1: The lateral wall is formed soley from the lateral joint fragment
    Type 2: The lateral wall is formed from both the lateral joint and body fragment
    Type 3: The lateral wall is formed soley from the body fragment
    The Sanders’ CT classification.
    The most commonly used classification system of displaced intra-articular calcaneal fractures is that of Sanders, based on a semi-coronal CT scan in the plane of the posterior facet. Primary fracture lines are described in the posterior facet (A- most lateral, to C- most medial). Fractures are then classified by the number of fracture lines in the posterior facet and their position. Type 1 fractures are those with less than 2mm displacement of articular fragments regardless of number of fragments. Type 2 fractures have 1 fracture line and 2 articular fragments and can be described as 2A, 2B or 2C depending on the position to fracture line. Type 3 fractures have 2 fracture lines in the posterior facet with 3 articular fragments and are described as 3AB, 3AC or 3BC. Type 4 fractures have 3 fracture lines and 4 articular fragments. Sanders 1 fractures generally do not need fixing, Sanders 2 should be considered for fixation with either an extended lateral or sinus tarsi approach depending on the other components of the injury (eg whether varus/medial wall can be reconstructed with a sinus tarsi approach). Sanders 3 injuries can again be considered for surgical fixation but are likely to need an extended lateral approach owing to the extent of the articular injury. Sanders 4 injuries may not be reconstructable although surgery to reconstruct the overall heel shape (height/width) or even primary fusion may be options.
    NON-OPERATIVE MANAGEMENT
    Patients with extra-articular fractures, minimally displaced fractures (less than 2mm joint displacement, minimal loss of height or heel widening) can be managed non-operatively. Non-operative treatment should also be carefully considered in older patients, those with significant medical morbidities and smokers, especially if considering open approaches, due to the significant risks of wound problems in these groups. The risk of wound problems should not be underestimated, wound breakdown with deep infection is a limb threatening condition. Non-operative management consists of splinting the foot, normally in an aircast type boot, off-loading the foot (non-weight bear for the first 6 weeks if possible) and early mobilisation of the foot and ankle joints under physiotherapy supervision.

    Intra-articular fractures of the Calcaneum. Part 1:Pathological anatomy & classification. Part 2: Open reduction and internal fixation by the extended lateral trans-calcaneal approach. J Bone Joint Surg (Br) 1993; 75-B 183-195.
    D. M. Eastwood, P.J.Gregg, V.G.Langkamer, R.M.Atkins. https://online.boneandjoint.org.uk/doi/abs/10.1302/0301-620X.75B2.8444934

    Setup

    Full lateral position.
    Thigh tourniquet at 300mm Hg.
    Peri-operative antibiotics and LMW Heparin.
    Image intensification from the start.

    Operation – 1

    A “tongue-type” calcaneal fracture.
    The posterior facet is depressed en-masse(A), with a large segment of bone posterior to it in-continuity, the fracture line exiting at point B.
    The small vertical yellow line(1) marks the most superior part of the posterior facet, here clearly depressed. A line drawn between this point to the highest point of the tuberosity(2)and another again from this point to the top of the anterior process(3) should make an angle behind their point of intersection. This is known as Bohlers angle and should be between 20 to 40 degrees.
    Here it is 0 degrees indicating complete depression of the posterior facet.
    If considering surgical treatment it is key that cross sectional imaging is undertaken with a CT, without which adequate assessment of this very 3 dimensional bony injury is not possible.

    A joint-depression type calcaneal fracture.
    The posterior facet has clearly been driven into the calcaneus, being both inferiorly translated and also antero-inferiorly rotated (in the line of the black arrow).
    Key to this being a Joint-depression type is the fact that the secondary fracture line is exiting superiorly(4) and not posteriorly as with a tongue-type fracture.

    A CT of the fracture is vital in assessing whether the fracture warrants reconstruction and then to plan that reduction. All 3 planes need to be assessed.
    There are various key points to assess on the coronal CT.
    These are as follows :
    1.How comminuted is the posterior facet: and therefore how reconstructible is the intra-articular part of the fracture ?
    On the left CT slice annotations 2 & 4, and 3 & 4 on right image, mark the main fragments of the posterior facet. There is some comminution but this does appear worth reconstruction.
    All coronal slides need to be studied as do the sagittal sections to get an accurate appreciation of the state of the joint.
    2. Is there varus or valgus heel deformation to be corrected? .
    This is also usefully looked for on the axial views.
    3.Is the sustentaculum in an anatomical position: This is the key point of fixation for the initial lateral to medial posterior facet screw.
    Rarely it can also be depressed and will require elevation before being fixed into.
    4.What makes up the lateral wall of the fracture?: This gives one an appreciation of what anatomy will present itself initially through a lateral exposure.
    Here it is a combination of the lateral joint fragment (2 in the left image and 3 on the right image) as well as the body fragment (3 in the left image and 5 on the right).
    This knowledge is helpful intra-operatively, when first exposing the fracture and forms the basis of the Atkins classification. This is a type 2 according to this classification.
    Intra-articular fractures of the Calcaneum. Part 1:Pathological anatomy & classification. Part 2: Open reduction and internal fixation by the extended lateral trans-calcaneal approach.
    J Bone Joint Surg (Br) 1993; 75-B 183-195.
    D. M. Eastwood, P.J.Gregg, V.G.Langkamer, R.M.Atkins.

    It is difficult to be sure what has made up the lateral wall in this malunited and inadequately treated calcaneal fracture.
    The majority of the body and lateral joint have been extruded laterally and allowed to unite in this position. The peroneal tendons will have been significantly displaced and compressed laterally.
    The sustentaculum has become a weight-bearing structure and the normal support for the talus within the ankle mortis can be expected to be compromised, as is evident in a couple of images.

    A reminder of where the lateral aspect of the calcaneus should sit in relation to the talus.

    The same malunited calcaneal fracture as shown in the coronal section (slide 4), demonstrating a grossly degenerate subtalar joint, and also loss of normal support for the talus.
    This patient has painful subtalar arthritis (1), plantar pain from a large bony boss of malunited bone (2)as well as anterior ankle impingement(3).

    The salvage procedure for the previous case is a distraction fusion of the subtalar joint. A large tricortical iliac crest graft (1) and morcellised autograft (partly from debridement of the lateral wall and plantar aspect of the calcaneus) are impacted into the prepared and corrected subtalar joint to re-support the talus posteriorly and allow it to return to its slightly plantar-flexed normal alignment (2).

    A critical part of the operation is setting the patient up so that adequate images are obtained to assess both the reduction and subsequent fixation of the fracture.
    The patient should be placed securely in the full lateral position , with padded side supports both front and back.
    A pillow between the legs will need to be fastened down with tape onto the table to prevent it moving around. The foot to be operated upon is elevated on a padded bowl as seen here. The lateral image should then be checked

    The image intensifier should be turned to allow the sole of the foot contact with the flat “reciever” end of the intensifier and source located posterior and proximal to the calf.
    This picture shows this set up from the bottom of the table with the foot obscured. The key position of the foot on the X-ray receiver is shown in the next image

    This is the type of position the foot needs to be in relative to the intensifier to get a good axial view of the calacaneus.
    It is key that this image is seen and both surgeon and radiographer are clear on how to position the C arm to reproducibly achieve this.
    The axial and lateral Image Intensifier projections will need to be moved between easily and predictably during the operation.

    The position of the beam relative to the calf to allow a good axial “shoot through” view.
    Once good images in both these plains are seen the Radiographer should make clear note of the position of the Intensifier and demonstrate an ability to reproducibly deliver these key pictures, by swinging the rig between them again before the limb is draped.

    The extended lateral (Atkins) type approach to the fracture, which is designed to avoid injury both to the sural nerve and the posterior peroneal artery, which supplies the superior flap that one is about to raise.
    The inferior limb of the incision is placed at the junction of the plantar type skin and dorsal foot skin, which easily identified.
    It starts at the 5th metatarsal base and extends posteriorly as a straight line, to meet the descending vertical limb. This is described as starting in the midline, about 12 cm above sole of the foot, and descending in a straight line to meet the horizontal limb about 2cm anterior to the tip of the heel, the angle of intersection being not less than 100 degrees.
    Roger Atkins original paper identifying safe landmarks for the incision by means of cadaveric dissection of the regional anatomy is very much worth reading and the full text is available free download from the British Journal of Bone and Joint.
    The extended lateral approach to the hindfoot. Anantomical basis and surgical implications. Brian J. C. Freeman, Sarah Duff, Patricia E. Allen, Helen D. Nicholson, Roger M. Atkins.
    J Bone Joint Surg [Br] 1998;80-B:139-42.

    The incision is deepened onto bone, initially at the point where it changes direction at the apex of the heel.
    This point should be sharp dissected directly down onto the calcaneus with a knife, avoiding any undermining of skin edges.
    Once on the bone this dissection plane is then progressed with a combination of sharp sub-periosteal dissection, placing the soft tissues under tension as seen with the Wests’ retractor.
    Blunt dissection with a large, round-nosed periosteal elevator is also used to elevate the anterior flap. The peroneal tendons are being lifted off the bone anteriorly within their soft tissue envelope.
    The aim is extend this exposure superiorly to the subtalar joint and anteriorly to the calcaneo-cuboid joint.

    Inferiorly and anteriorly one encounters the the muscle belly of Abductor Digiti Quinti, which extends forwards the length of the incision.
    This needs to be divided in the line of its fibres with a knife and then elevated off the calcaneus, using sub-periosteal dissection aided by traction on the muscle with the Wests retractor.
    The calcaneo-cuboid joint defines the anterior extent of the exposure.

    When extending the incision deeper superiorly a fine dissecting scissor should first of all be used in the fat layer, to assist in avoiding the sural nerve, which has some normal variation in its path.
    The objective is to clearly define the superior aspect of the Calcaneus (1) and in doing so also the exact location of the Achilles, so it can be protected.
    The dissection should also proceed anteriorly to expose the posterior aspect of the posterior facet. This is achieved by further subperiosteal elevation of the anterior flap(2)

    Two Wests retractors are usually required if operating single handed. It is important to frequently relax them and the soft tissue envelope. It is also key that they should be placed deeply, not directly on the skin edge.
    The initial presentation to the surgeon of the fracture is by its lateral aspect. Unless one is aware of Atkins “lateral wall” classification, and has made an assessment of this part of the fracture on the pre-op CT, then this aspect can cause some disorientation to the surgeon.
    The lateral aspect of the calcaneus that is exposed (1) may either be wholly made up of the “body” fragment(deep to which the posterior facet or lateral joint fragment has been impacted) or wholly the lateral joint fragment or a combination of these two parts of the calcaneus.
    The coronal CT should be studied to understand what the lateral fracture anatomy is.
    The McDonalds (2) can be usefully employed to identify both the superior aspect of the Calcaneus as well as the Achilles tendon.

    Here the lateral wall (1) is formed entirely by the body fragment, which has further split.
    This large fragment needs to be carefully elevated, then removed & saved, before the subtalar joint can be accessed, and the posterior facet identified reduction commenced.

    With the large body fragment removed(1), the posterior facet of the subtalar joint can now first be seen, deep to it (2).
    This fracture has also fractured through the Angle of Gissane (3), which is partly obscuring the field. This will be a dense piece of well defined cortical bone.
    There is also fracture haematoma (4) further obscuring the view.

    With the loose body fragment removed the en-masse depression of posterior facet and superior aspect of the calcaneus (1), as anticipated from the CT, becomes evident.
    The Angle of Gissane (2) has now been elevated with a small Langenbeck retractor, which also aids visualisation of the intra-articular anatomy.

    Elevate the posterior facet through the fracture site (arrow). This may well be comprised of various fragments, and the best fit for these needs to be judged.
    The Angle of Gissane is often intact and is a useful point to match up to the most anterior aspect of the posterior facet, allowing one to assess how adequate reduction has been.
    In this case it has fractured and is currently elevated and behind the Langenbeck, but remains a substantial fragment which helps with orientation of the reduction when replaced.
    A gap is of course produced (1) within the body of the calcaneus after reduction of the posterior facet, and one may choose to graft this defect.
    Rarely the sustentaculum tali medially also requires elevation, which is done through the fracture site. One will have had judged this already on the pre-op CT. This structure may be identified intra-operatively by a combination of palpation of the medial wall and visualisation through the fracture site.
    One should bare in mind that its inferior relation, beneath the Flexor Hallucis Longus tendon, is the neurovascular bundle.

    With the posterior facet elevated(2) and Angle of Gissane about to be relocated (3) any heel varus or valgus deformity should be corrected.
    The anterior process of the calcaneus should also be exposed, either simply to allow positioning of the plate to be used or also to permit reduction of extension into this joint.
    Once this is done a stout guide wire (1) is driven through the heel, the posterior facet and finally into the talus, to hold the reduction.
    The axial and lateral X-rays should now be repeated to confirm correct positions.
    The peroneal tendons (4) are seen superiorly retracted.

    An additional wire is placed to hold the reduction of the Angle of Gissane (1). This is usually a well maintained part of the bony anatomy that should indicate that a good reduction is has been achieved, when it slots into place.
    It is very evident that there is significant effective bone loss resulting from the fracture, once the main fragments have been reduced back anatomically(2).

    One or two additional wires (1 ,2) are placed to allow cannulated screw fixation from the superior aspect of the posterior facet, across into the sustentaculum.
    Only one screw is required.

    Normally a small fragment, cortical lag screw (1) is used to fix the posterior facet. A washer may be required if bone quality is poor.
    Before this screw is placed the correctly sized plate should be contoured to the calcaneus and trialled onto the lateral aspect of the bone.
    Ideally the placement of this initial screw should not compromise the subsequent plate fixation.
    An axial X-ray is required at this point to ensure this screw has not over-penetrated the medial wall. I

    Following fixation of the posterior facet (for which the small fragment screw head is visible) the lateral wall body fragment can be replaced (1), over graft if this has been used.
    How well this fragment fits back also gives a good idea of how adequate reduction has been.
    The heel and “Gissane” wires holding the reduction remain until plating of the fracture has been completed.

    Operation – 2

    In this case a locking calcaneal plate is used.
    The first generation plates were non-locking and screw purchase into this mainly cancellous bone was on occasion an issue, a problem solved by the locking plate.
    Different sizes are available according to calcaneal dimensions.
    The plate needs to be contoured, in particular the limbs that skirt behind the posterior facet, A, rest on the dorsal aspect of the anterior process, B, and contain the most posterior and superior part of the bone, C.
    There are plenty of holes to fix into, which accommodates for the fact that a number of these will sit over fracture lines and will be of no use.
    Fixation proceeds first beneath the posterior facet (1,2), followed by the anterior process (3,4) and finally the tuberosity (5). If a tongue type extension is also present a superior to inferior long screw is angulated from the most posterior and superior hole if the thread geometry allows, or is used outside the plate.

    As in this case, it is not unusual for a number of the holes on the plate to be unusable due to fracture line position. These areas can be grafted if required.
    The plate acts in part as a scaffold to splint the calcaneus to its anatomical dimensions whilst it heals.
    Closure is in layers over a deep drain.
    Most patients will be splinted for an initial 2 weeks in a cast, with regular wound management. Early non-weight bearing joint mobilisation is allowed in those with stable reductions and stable personalities beyond this point, in a post-operative boot.
    Weight bearing to commence from 5 weeks or so.

    Following fracture reduction and internal fixation of the same fracture both Bohlers’ angle (posterior to the point of intersection 1) as well as the angle of Gissane (2) are easily identifiable with this on-table image.

    The axial view of the reduced and fixed calcaneus.
    The key points in the reduction are that Calcaneus is
    longitudinally aligned, with neither a varus nor valgus tilt.
    The Sustentaculum tali (1) is correctly aligned at approximate right angles to the long axis of the Calcaneus.
    The length medially of the screws used to fix into the sustentaculum(2) can be easily checked. One should be aiming to avoid penetrating the medial cortex as this risks neurovascular injury in this area.

    Fixation of an intra-articular tongue-type calcaneal fracture.
    The order of fixation here will have been:
    A. Transfixing screw into the sustentaculum (1), to stabilise the reduced posterior facet fracture.
    B.Fixation into the plate using as many holes as sit over solid (non-fracture line) bone, initially in area 2, followed by the anterior process, 3.
    C.Contouring of the plate at point 4 to capture the tongue fragment. This superior hole can be used to fix almost vertically, but in this case the bone beneath this was poor.
    D.Fixation of tongue fragment, 5.
    E.Final fixation into remaining good bone, 6.

    Post Operative

    Peri-operative popliteal block for pain relief & oral analgesics
    Deep drain, removed at 24 hours
    Elevate 24 hours-48 hours
    Dressing changes at 1 & 2 weeks
    Below knee backslab 5 weeks. This is however not an absolute. In reliable and motivated patients with stably fixed fractures some joint range of movement excercises can be started from as soon as the wound has settled (3 weeks plus). They should however remain non-weight bearing till 5 weeks.
    Non weight bear 5 weeks
    Into long post-operative boot at 5 weeks to commence weight-bearing after Xray
    Care to be exercised with wound even once in post-op boot .Dressings should continue to avoid scar rubbing which predisposes to both superficial wound breakdown and cellulitis.
    Physio rehabilitation to work on subtalar & ankle mobilisation/strengthening from 5 weeks
    Balance work from 7 weeks & functional rehabilitation there-after.
    It is possible post-operative boot may be discardable from 10 weeks post-operatively if appropriately supportive & shock absorbing shoe-wear is available.

    Recommended Reading

    Intra-articular fractures of the Calcaneum. Part 1:Pathological anatomy & classification .Part 2: Open reduction and internal fixation by the extended lateral trans-calcaneal approach. J Bone Joint Surg (Br) 1993; 75-B 183-195.
    D. M. Eastwood, P.J.Gregg, V.G.Langkamer, R.M.Atkins.
    These are both landmark papers and essential reading for anyone learning to treat Calcaneal fractures operatively. The classification system prepares one for the way the fracture will present itself when exposed by a lateral approach (as a fragment of lateral joint , the lateral joint and part of the body of the Calcaneus or just the body of the Calcaneus ). The extended lateral approach is worthy of understanding and adopting given the low incidence of wound breakdown and Sural nerve injury associated with it.
    The mechanism, reduction technique and results in fractures of the Os Calcis.
    The British Journal of Surgery . 1953; 395-419.
    Peter Essex-Lopresti.
    A Landmark paper to be read for interest.
    Long-term functional outcomes after operative treatment for intra-articular fractures of the calcaneus.
    J Bone Joint Surg.2009.91-A;1854-60.
    M.O.Potter , J.A.Nunley.
    81 operatively treated intra-articular fractures of the Calcaneus followed up for approximately 12 years. The follow up was by means of questionnaire sent to a larger group of 157 , 81 fractures (73 patients) responded. A large group & long follow up with a mean AOFAS score of 65
    Fractures of the Calcaneum. A review of 70 patients.
    J Bone Joint Surg.2004.86-B.1142-1145.
    M.Paul ,R.Peter ,P.Hoffmeyer .
    Small numbers ( 4 groups compared comprising both operative & non-operatively treated patients with normal/restored and abnormal/inadequately restored Bohlers angles) followed up for a mean of 6.5 years
    Patients treated operatively in whom Bohlers angle was better restored did better than those in whom this was not achieved. In the non-operative group with a reduced Bohlers angle 48% had constant pain (as did 22% with a normal angle treated non-operatively) though and 22% required subsequent subtalar fusion .The poorest outcome in those teated operatively without adequate restoration of Bohlers angle.
    Arthroscopic release for painful subtalar stiffness after intra-articular fractures of the Calcaneum.
    J Bone Joint Surg.2008. 90-B.1457-1461.
    K.B.Lee , J.Y.Chung , E.K.Song , J.K.Seon ,L.B.Bai.
    17 patients with pain & stiffness following displaced intra-articular fractures treated with ORIF or manipulation & casting.
    82% were better (14 patients). 2 unimproved required subtalar fusion. The time to arthroscopy was relatively rapid (a mean of 11 months or so) and the follow up post arthroscopy relatively short averageof 17 months. This is never the less a useful intervention for post-fracture intra-articular pain.
    Operative treatment in 120 displaced intra-articular Calcaneal fractures. Results using prognostic Computed Tomography scan classification.
    Sanders R, Fortin P, DiPasquale T, Walling A.
    The classification system first published in this paper has become much used in decision making and description of Calcaneal fractures. Type 1 (undisplaced) Type 2 (2 part or split type fractures) Type 3 (3 part or split /depression fractures) Type 4(4 part or highly comminuted fractures).
    CT scans repeated at a minimum of 12 months post operatively. The most prognostic factor was the reconstitution of the intra-articular anatomy (though in virtually all cases the extra-articular factors of heel height ,width and length were also restored). Excellent or good results reported in 73% of Type 2, 70% of Type 3 and 9% of Type 4 fractures.
    It is worth noting that 8 wound breakdowns occurred for which 5 free flaps were required to cover and 3 below-knee amputations ensued. These are often high energy injuries with associated other trauma.
    Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures
    Journal Bone Joint Surg. 2002.84-A(10): 1733-1744
    Buckley R et al
    309 patients from a larger initial cohort followed for 2-8 years. In some groups of those not receiving compensation payments operative intervention yielded superior outcomes. If compensation payments were not taken account of no difference was shown between the groups.
    5% deep infections and 17% superficial wound breakdown.


    Reference

    • orthoracle.com

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