Current Concepts in the Treatment of Intra-Articular Calcaneal Fractures

Abstract

PURPOSE OF THE STUDY The aim of this study was to evaluate and present the current concepts in the treatment of intra-articular calcaneal fractures. MATERIAL AND METHODS During the period of ten years (1/2007-12/2016) 162 dislocated intra-articular calcaneal fractures in 145 patients were treated and evaluated at the Trauma Department of University Hospital in Bratislava. The study group included 97 male (67%) and 48 (33%) female patients. The mean age was 42 years (10-66). 17 cases (11.7%) were bilateral calcaneal fractures. Twelve patients suffered a calcaneal fracture associated with polytrauma (8%), and 15 (10.3%) of such fractures were associated with a spinal injury. All of the avaluated fractures n=162 were classified according to Essex-Lopresti - 101 (62.5%) were depression type, 38 (23.5%) were tongue type and 23 (14%) were comminutive. The other used classification was according to Sanders - 95 fractures (59 %) were Sanders type II, 44 (27 %) Sanders type III and 23 (14 %) Sanders type IV. In operative treatment the indication criteria considered were fracture morphology, soft tissue involvement, age and overal patient physical condition. Plate osteosynthesis was used in 80 cases (49%) - in 34 fractures of Sanders type II, 44 in Sanders III and two cases Sanders IV type. Palmers modified approach (limited lateral approach) was used in 21 fractures (13%) - where 7 fractures (4.3%) were treated by screws, 12 (7.4%) with the C-nail and K-wires were used in 2 pediatrie patients (1.2%). In 38 patients (23%) in tongue-type fractures we performed percutaneous reduction (Essex-Lopresti/Westhues) and osteosynthesis with three or four 6.5 mm cancelous screws. 21 fractures Sanders type IV (13%) were treated with the external fixator. RESULTS The regular follow-up period was 6-36 months, with various functional results evaluated according to two scoring systems, namely the Creighton-Nebraska Health Foundation Assessment Score (C-N scoring system) and the AOFAS Ankle-Hindfoot Scale (A-H scoring system). In the whole study group in 125 (77%) treated fractures good and excellent results achieved, in 21 (13%) cases the results were satisfactory and in 16 (10%) cases they were poor. No deep infection complications were recorded, but in 14 cases (8.6%) iatrogenic complications such as incomplete reduction or mal-reduction, inproper indication or misdiagnosed compartment syndrome and 15 (9.2%) superficial infection were observed. DISCUSSION Despite the controversy as to the proper treatment of intra-articular calcaneal fractures, mainly in simpler types of Sanders type 11A and MB it is of benefit to use a combination of percutaneous reduction of calcaneal body along with the posterior articular surface from the Palmer s modified approach. CONCLUSSIONS At our department we prefer percutaneous reduction and osteosynthesis as a method of choice in tongue-type fractures, and the Palmers modified approach is the preferred method in Sanders type 11A and MB fractures. In Sanders type III fractures we advise to use the plate osteosynthesis and for Sanders type IV fractures an external fixator is recommended.