calcaneal fracture treatment by primary arthrodesis

Middle articular surfaceAnterior articular surface

Ebsterior articular surface

/LTrochlear process

artic. surface

process

Cuboid

Lateral process /

FIG. 1-A

Superior and lateral projections of the calcaneus.

VOL. 41-A, NO. 8, DECEMBER 1959 1423

Treatment of Comminuted Fractures of the

Calcaneus by Primary Triple Arthrodesis

liv KEAItNS It. THOMPSON, M.D., AND CARL M. FRIESEN, M.D.,

LEXINGTON, KENTUCKY

Thei’e are many varieties of fractures of the calcaimeus, but conuninuted

fractures are frequent and produce the greatest disability. In the treatment of

these fractures there is much clifferetmce of opinion and general pessimism as to theoutcoimme. ()tme of us (K.H.T.) begaim treating these fractures by primary triple

arthro(Iesis iii 1048, aimd it Imas been our (4xpet’ieimce that this procedure producesa iiigim �)ercentage of satisfactory results.

ANATOMY

r1�i calcaimeus, \ViliCil is tiit� largest 1)01-ic in time foot, tti’ticultttes superiorly

-i��ith the talus aim(1 antei’iorlv with time cuboid. Timere are three superior articularsurfaces: the posterior, the middle, and time anterior (Fig. 1-A). �Fime posteriorarticular surface is tlonie simaped, is i iicli imed obliquely forward at approximately

45 degrees to the bug axis of the body, and is the largest of these articular areas.rfIlc elongated i-imedial at’ticular surface is usually divided into two parts by a imotch.The area posterior to the notch at-id lying anterior to the posterior articular sur-

face is tie middle articular surface; it is supported by the sustentaculum tali. Thearea anterior to the posterior articular surface and lateral to the middle articularsurface is the calcaneal sulcus; it forms the inferior half of the sinus tarsi. Theposterior portion of the calcaneus is the tuberosity, whereas the anterior projec-tion forms the cuboid articular surface. Superior and medial to the cuhoid articu-

lar surface, a hone pronmitmence is evident, which is called the anterior process.

Sustentaculum

tall )‘�

t�Tuberosity-�

* Read at time Annual Meeting of The American Academy of Orthopaedic Surgeons, Chicago,

Illinois, January 27, 1959.

Lateral Medial

A. Normal tuber-joint angle

Fm. 1-13

Inferior l)rojectiorm of time calcaimeus.

FIG. 3 FIG. 4

Fig. 3: Aiiteroposterior roentgenogram of time ankle, showing fracture of the calcaneus, with

lateral sI)read.Fig. 4: Case 3 (Table II). Lateral roentgenogram of time caleammeus, showing :m (olmmnmiimuted frac-

ture of time entire body, involving time subtalar and calcaneocuboid joiimts.

1424 K. R. THOMPSON AND C. M. FRIESEN

THE JOURNAL OF BONE AND JOiNT SURGERY

B.

B. Ceiling line

Fi.. 2

1)rawing of the ceiling line.

The cuboid articular surface is concave from above do�vn�vard and lateralward

and convex in a direction at right aimgles to this. As has been pointed out byShephard, the coimfigurations of the articular surfaces of the (alcaneocuboid joitmt,of the ball-and-socket talonavicular joint, at-id of the sui)talar joint allow medial

and lateral motions of the foot. �fh calcatmeus, whemi visualized from below (Fig.1-B), exhibits a lateral bowimmg, or convexity, atmd a inetlial concavity.

1WENTGENOGRAPHI(’ EVALI�ATI0N

As far back as 1720 (according to Goff), Garat-igeot described the “smashedfracture”. With the discovery of roentgen rays in 1895, Desfosscs offered the first

accurate interpretation of the fractured calcaneus. In 1908 Cotton aid ‘Wilson

described their manipulative technique for treatment of this fracture, based onroentgenographic interpretatioim. Most investigators during the past fifty years

have recommended that the roentgenographic diagnostic survey of a patientwith a I)aitmftll heel after iimjury should include an anteroposterior projection of

Fig. 5-A Fig. 5-B

COMMINUTED FRACTURES OF THE CALCANEUS 1425

VOL. 41-A, NO. 8, DECEMBER 1959

Fig. 5-A : Case 9 (Table I ). Lateral roentgenogram of time (alcaneus, simowing a severe depressionfracture of the Posterior articular surface as well as time anterosuperior articular surface, withavulsion fractures of time posterior aspect of the talus and of the eui)oid.

Fig. 5-B: Case 9 (Table I). Postoperative lateral roentgenogram after triple arthrodesis in whichtwo staples were utilized for internal fixation, showing restoration of the trai)ecular p:mtterim acrosst he artimrodesed joitmts

time atmkle, a lateral lrujetioim of time ankle and calcatmeus, atid aim axial ( l)lalitar)

pt’ojectioii of the calcatmeus. 1’rolmi our experience we believe that two additiotmal,

although l)l’eviOtlslY described, projections are necessary: a lateral-oblique pro-jection of the calcaneus and an anteroposterior projection of the mid-tarsal

j oitmts.In tile anteroposterior projection of the ankle joint, injuries of the ankle,

as well as lateral spreading of the calcaneus (Fig. 3), can be detected. In addition

to visualizing ti-ic fracture lines, the lateral projection permits the evaluationof the tuber-joint angle of B#{246}hler(Figs. 4, 5-A, arid (3-A), as well as the “ceilingline” described by�G. E. \Vilson (Fig. 2). This lit-ic joitms the anterosuperior withthe losterosuperior aimgle of time calcaimeus. Lateral roentgeimographic i mmterpreta-tion, as was pointed out by C. E. Wilson in 1950, is also dependent on the positiotmof tiw foot at ti-ic time that ti-ic roentgenogram is made; that is, vhetimer the foot

is inverted or evei’ted. An axial (plaimtar) projection shows the medial malleolus,

the lateral mallcolus, time base of the fifth metatarsal, medial concave and lateralconvex surfaces, the fractured sustentaculum tali (Fig. 6-B), at-id fracture of the

l)osterior articular surface (Fig. 7).Time two additional projections used by us show involvement of the articular

sui’face of time calcaneus at the calcaneocuboid joint, which is not evideimt in the

convetmtiotmal lateral projection. The lateral-oblique projection visualizes fracturesitivolving this articular surface (Figs. 6-C at-id 6-D), as well as fractures involving

the anterior process, whereas ti-ic anteroposterior projection of the mid-tarsal

joints shows fractures involving the articular surface of the calcaneus at the

calcaimeocuboid joint, which frequently are associated with a lateral spreading dis-placeim-ient of the lateral cortex at the joint (Fig. 8-B). As has been pointed out by

Conn, depression of the articular surface and joint incongruity are also present.In the more severe fractures, medial subluxation of the talus at the talonavicularjoint takes place (Fig. 9). There has beet-i lack of emphasis on the importance ofthese two projections which portray fractures involving the anterior articularsurface as well as any abnormality il-i the talonavicular�joint. We believe that sot-i-ic

of the unsatisfactory results encountered in the past with treatment other than

triple arthrodesis are because of the lack of recognition of the associated injuriesinvolving the two peritalar joints. Proper evaluation of the extent of time commi-

nuted displaced fractures is only possible on the basis of these five roentgenographicprojections.


CLASSIFICATION

In 1952 Essex-Lopresti presented a classification of caicaneal fractures:Group 1 : Not involving subtalar (“subtaloid”) joint

A. Tuberosity fractures1. Beak type (Boyer)2. Avulsion of medial border

3. Vertical4. Horizontal

B. Involving calcaneocuboid joint1 . Parrot-nose type2. Various

Group 2: Involving subtalar (“subtaloid”) jointA. Without displacementB. Tongue type, with displacementC. Centrolateral depression of jointD. Sustentaculum tali fracture aloneE. With gross comminution

1 . From below (including severe tongue and joint-depression

types)2. From behind forward, with dislocation, subtalar (“sub-

taloid”) jointThis paper considers only those fractures of the second group, with displace-

ment and involvement of the subtalar joint. In B (tongue type with displace-ment), C (centrolateral depression of the joint), as well as E (with gross corn-minution), decreased tuber-joint angle, cornminution, and deformity are exhibited.We found that these fractures exhibit, in addition, extension forward of thefracture into the cuboid articular surface, with lateral spreading. Also common,and evident in the more severely comminuted fractures, is subluxation of the

talar head at the talonavicular joint. Fracture of the cuboid articular surfaceof the calcaneus should always be considered as an aspect of comminuted fracturesof this bone because of its usual occurrence and the disability it produces. We be-lieve that the fracturing force bows the lateral cortex of the calcaneus like a barrelstave, producing the lateral spread of the bone and the extension of the fractureinto the articular surface at the calcaneocuboid joint (Fig. 10).

REVIEW OF TREATMENT

In 1938 Goff presented a comprehensive review of the literature which in-eluded 151 references. The disability produced by comminuted fracture of the

caicaneus was recognized early, and in 1912 van Stockurn reported open reductionwith subtalar arthrodesis. Magnuson drew attention to the upward displacementof the posterior fragment and, in 1917, recommended subcutaneous tenotomy ofthe Achilles tendon to eliminate this upward pull, combined with manipulationto break up the impaction and force the heel downward. He immobilized the footin a plaster cast in a position of strong inversion and equinus. In 1923 he was the

first to recognize the lateral piling up of bone beneath the external malleolus andrecommended removing this mass and creating a trough for the peroneal tendons.This was followed by manipulation of the calcaneus, shifting it medially with the

use of a wrench if the subtalar joint was not ankylosed and if manipulation waspossible. Cotton also called attention to the disabling aspects of the piling up lat-erally, as did Cabot and Binney.

With continued dissatisfaction with results obtained from closed manipula-

tive procedures, attention was focused on surgical management. In 1927 P. D.Wilson pointed to the contributions of Conn, Allison, and Reich, who, in 1926,

recommended arthrodesis of the subtalar joint. He reported twenty-six patientson whom he did twenty-eight subtalar arthrodeses. In his experience, early opera-tion-that is, on patients with recent fractures-gave the best results, with an

THE JOURNAL OF BONE AND JOINT SURGERY

Ftc. 6-A

.�. ,fr

Fin. 6-13

Fic. 6-C Fia. &-D

Fig. 6-C: Photograpim showing time positioniimg for time lateral-oblique view, to show fractureinvolveimment of the calcancocuhoid joint.

Fig. 6-1): Lateral-oblique roermtgermogranm of the calcaneus, showumg the fracture extending intotime cuhojd articular surface.


VOL. 41-A. NO. 8. DECEMBER 1959

Fig. 6-A: Case I (Table II). Lateral roentgetmogram of the calcaneus, showing a toimgue-tvpe

fracture.Fig. 6-13: Axial (plant ii) meat gcnograimm of time calcaneus, showiimg a fract tire of t lie sustentaru-

luin tali.

avet’age (listti)ility period of live and one-half timonths. Old fractures treated by thistmmethcul (lid less W(ll, with an average (lisal)ility period of eight mmotmths. Wilsotm

also l)(tfol’tmled aim tLI’thro(lesis of the talonavicular joint ill 5011W itmstances, and

h)llti(l that results seetne(1 to l)e ituproved by this addition. lie was atnotmg timefit’.st to mnetitioti that occasionally time calcatmeOCul)Oid articulation is involved by

time fracture. It is belieVc(l that his (letectiOti is of key itnportance, and otie whichhas gone unrecognized by niatmy subsequent itmvestigators of time counminuted

fracture. To further cite Wilson, he believed that a foot is better, solidly fused ina Iosition of optimum function, than with limited tnotion, unfused and paitiful.lie believed that there is tmo great amouimt of remaining motion, regardless of

treat meimt.It-i the following decade ti-ic pendulum swung back, at-id closed treatment

tame into vogue agaitm. In 1931 B#{246}iulerdescribed his InetilOd, in which he utilizedskeletal fixation with Steintnatmti pitis it the tuberosity of the calcaneus at-id in the

lower tibia. The significant feature of this method was the attempt to achieve

at-i accurate reduction usitmg time tuber-joint angle as a guide. This angle, which he

/

I

F1(. 8-B



I �= r described, is formed by the intersection of

a line drawn along the upper contour of

the tuberosity and a lit-ic uniting the highest� � point of the anterior process with the high-� est point of the posterior articular surface.� This angle is usually 30 to 35 degrees.

� B#{246}hleremphasized the significance of this� � atmgle in the diagtosis at-id reduction of frac-

� tures of the calcatmeus, but whet he used it

� as a guide to reduction he did tmot take itito

� consideration the fact that even though the� atmgle is restored, the joitmt surfaces may miot

i)e returtmed to nortmmal nor tnay comnmnitmuted� fragmeimts be realigtmed. B#{246}hlerreported the

-�------�---��-.-�� .�use of this method of treatim-ient in 100 cases

FIG. 7 but he did not give etid-t’esult statistics.

Axial (iilantar) roentgeimogranm of the This method was somewhat uniformnly(‘al(’aneus, showing time fracture of time adopted, with efforts directed to techmuiquesl)osterior articular surface. to restore the contour of the calcaneus.

Corm, il-i 1935, was among the first to appreciate the extent of these fracturesas well as to anticipate disability. He found 85 per cent of fractures of the cal-caneus to be of the smashed type. He pointed out, in his anatomical description,that frequently the sustentaculum tali is depressed and the subtalaf joint dis-rupted. He also noted that the talonavicular joint is often subluxated and that thefracture involves the calcaneocuboid joint. He emphasized that, with these altera-tions in joint alignment and the resultant disturbance of the normal weight-

bearing thrusts, the reason for both the pain and the failure of simple subtalarfusion is quite evident. He proposed a two-stage method of treatment. First, theimpaction was broken up by using a heavy wooden clevis, and the fracture wasimmobilized by a modification of the B#{246}hlertechnique. In the second stage, five

weeks later, a triple arthrodesis was performed. He reported on nineteen fresh frac-

tures treated by this method, with excellent results in all but two. Triple arthrod-esis on six old fractures gave five good results.

Other modifications of the original Cotton procedure were described byHermann it 1937 and by Goff in 1938. In 1943 Gallie reported his operativeprocedure of subtalar-joint fusion for which he used a posterior approach. He

�

FIG. 8-A

Fig. 8-A: Photograph showing positioning for the a1mteropost4�rior view of time nmid-tarsals forvisualization of the talonavicular and calcaneocuboid joints.� Fig. 8-B: Aimteroposterior roentgenogram of the mid-tarsal joitmt, showing the fracture extendinginto the calcaneocuboid joizmt, with lateral spread.

I

t�1’

CAL CAMEl

Ftc. 10

COMMINUTED FRACTURES OF TilE CALCANEUS 1429

VOL. 41-A. NO. 8. DECEMBER 1959

1�t(;.U

l’ig. U : ��1It(io!asteiior iO(iltgeiiOgialfl of t ime niid-tarsal joint , shmo�ving I he fract ore

cxten(lnmg iimto the (alcaneocul)oid joint and sui)luxation of t lme imead of t he talus (comparewith Fig. 8.13).

Fig. 10: !)ra�ving of the authors’ coimception of the mecharmisnm of fracture involveumentof t in (Ui )Oi’ I art icular surface.

Case 5 (Table I). Lateral roentgeimogram of a triple arthro(l-esis, six arm(l one-half years after operation, showing time stapletraiisfixing time caicarmeocui)oi(l joint.

listed varus of the heel or other deformities as contra-indications. Harris, in

1946, recommnen(led a t1mree-pin�type of traction, which he labeled tn-radiatetraction, in which he used a ring with screw adjustmetmts. Ten days after reductionhe did a 1)ostenior subtalar fusion of the (Jallie type through a window in theplaster at-id removed plaster at-id pit-is eight weeks later. lie also recommendedutilization of a Steinmnammn pim driven it-ito the heel to pry up the depressed frac-

tures; this was also necommnended later by Gissatme. Geckeler and Dick each re-ported his results of treatment by subtalar arthrodesis; Dick used grafts of can-ceilous botme, either homogenous from the bone bank or autogenous from the iliac

crest. Of ti-ic nine patients he reported, all showed sound fusions and returned towork within an average period of six au-id one-half months. In 1946 Pridie described

excision of the calcaneus in the treatment of these severe fractures. He believedthat this was indicated because of the disruption of the subtalar joint with theresultant stiffness, pain, and disability which usually follow this type of fracture.

1 58* M It Farmer 5 6 E 22 36 M L Teacher 3 . 3 4 E 7.7:3 4:3* M I� Tobacco laborer :3 6 1� 7

I 49* M L� Construction

worker3 . 5 6 U I

5 55t r�i R

L

Roofer 33

77

EE

6.56.5

6 37* M R Mover 4 7 E 1

7 49 M R Truck driver 3 6 E 3.38 45*t M R Exercise boy 3 6 E 59 30 M L Farmer 3 7 E 1

10 35*t M R Farmer 3 4.5 E 4.51 1 35* M R Tobacco worker 3 5 G .5

12 47* M L Lumberworker 3 4 E 1.513 30* M R Laborer 3 5 E 1.3

14 6O� M It Mason 3 5 E .7

15 39* M R Farmer 4 5 E 1.516 28* M R Tobacco laborer 3 4 E 2.3

17 49 M R Contractor 4 11 F 2.518 49 M L Carpenter 2.5 11 G 1.819 56 M

Averages:L Electrician 3

3 . 3

56 . 0

E 8.53 . 1

*Comp�nsab1e cases.

tBilat.eral fracture.

�E = excellent; G = good; F = fair.



TABLE I

COMMINUTED FRACTURES OF THE CALCANEUS TREATED BY PRIMARY TRIPLE ARTHRODESIS

IN PATIENTS WITHOUT ASSOCIATED INJURY

Age

Patient (Years) Sex Side Occupation

Roentgenographic

Healing

(Months)

Back to Work Results Length of

after Surgery Follow-up

(Months) (Years)

The results in two of the fifteen cases he reported were not satisfactory, andamputation was necessary in one.

In 1948 Palmer described open reduction and elevation of the depressedfragment of the posterior articular surface after a transfixion wire was placedin the tuber calcanei in order to apply downward and backward traction. Thecavity left by elevating the fragment was filled with a graft of cancellous bonefrom the ilium. Essex-Lopresti, in 1952, described open reduction, pointingout that in 1902 Morestin first advocated open reduction. Open reduction wasalso described later by Leriche in 1913, by Lenormant, Wilmoth, and Lecoeur in1928, and by B#{233}rardand Mallet-Guy in 1929, as well as by Simon and Stultz in193 1 . In the procedure described by Essex-Lopresti a graft was not used in theearly cases since it was found that the cavity filled with cancellous bone and wasnot visible roentgenographically after eight weeks. However, if the operation wasnot performed within two weeks of injury, there was the likelihood that the cavitywould not fill with new bone. In 1955 Allan and Maxfield and McDermott reportedtheir experiences with open reduction and bone-grafting, using the technique

described by Palmer. Whittaker, in 1947, described open reduction through amedial approach done on three patients ; his eight-year follow-up was reported in1954. In 1957, Thompson and Hughes and Leonard recorded their results afteropen reduction and grafting. Leonard used hornogenous bone in order to avoiddisability at the donor site.

RATiONALE AND INDICATIONS FOR TRIPLE ARTHRODESIS

From the literature it would appear that comminuted, displaced, calcanealfractures cannot be successfully treated by closed manipulative procedures.Essex-Lopresti defined the comminuted fracture as one which has a primary frac-ture line which involves the body anterior to the posterior articular surface and a



TABLE II

Cu�I-iiIx UlEl) FRM It lIES OF THE CALCANEUS TREATED BY PRIMARY ‘fRI liE ARTIIRO1)ESN

IN 1�ATIENTS WITH ASSOCIATED INJURY

Roentgenographic Back to Work Length of

Age Healing after Surgery Follow-ui)

Patient (Years) Sex Side Occupation (.ifonths) (Mont/is) Resultt (Years)

1 20 M R Student :3 I 1� 5.52 :32* � M it Riveter :t .5 7 E U

3 44* �#{149}�;�t it Carpenter 3 8 E 6.7

4 21 � � F It housewife 2.5 9 li 4.5

5 3O�’ #{149}� M L Druggist 3 .5 I 1 E 4.76 59*� � M L Carpenter :3 10 E 6.3

Averages: 3. 1 8 . 2 6 . 1

*Compensai)le cases. tE = excellent; U = good; F = fair.

secondary fracture lit-ic which traverses the body just behind the joimt. The fnag-ment outlined by these fracture lines includes the lateral half or lateral two-thirds

of the posterior articular surface. When displacement occurs this fragment isdriven downward while the tuberosity is driven upward. The primary fractureline opemms infeniorly, and there is associated widenimmg of the body of the calcaneus

due to lateral displacement of the fragments. In addition, as demonstrated in ourcases, another fracture lit-ic extemds forward ot the lateral side into the articular

surface at the calcaneocuboid joint.In the past, arthrodesis of the im-ivolved joitmts has beenrecomrnended by

various investigators on the assumption that irreparable damage to the articularsurfaces has occurred ani that aseptic necrosis of some of the fragments amid

arthritic changes vill supervene. A one-joint or subtalar fusion was recommendedat first. Them-i a two-joitmt arthrodesis including the subtalar and talonavicularjoints was recommended by Wilson in 1927. Finally, a three-joint or triple arthrod-esis was advocated in 1935 by Conn and subsequently by Geckeler who empha-sized the importance of doing a triple arthrodesis when the calcaneocuboid jointwas involved. With the realization that the calcaneocuboid joint is frequemitly

involved it is our feeling that more surgeons will want to recommend triplearthrodesis.

By appropriate roentgenographic technique we have beet-i able to identify thecomminuted displaced fractures which disrupt the subtaiar joint and involve thecuboid articular surface of the calcaneus at the calcaneocuboid joint as well ascause alteration of the tuber-joint angle and lateral spreading. Patients withthese fractures have been selected, irrespective of their age, for primary triplearthrodesis. Twenty-five patients with twenty-six fractures treated by this tech-nique are reported in this study.

PREOPERATIVE CARE

Care before surgery varied, depending primarily on the general condition ofthe patient and on the interval betweemi injury al-id examination. Surgery was un-dertaken promptly before there was marked swelling if the patient was seen early.When the patient was not seen early, and when swelling was significant, general

supportive measures were used until the local skin condition was believed to be

satisfactory for operation. In some instances it was necessary to wait for edemablisters to heal, particularly when the fracture was severe ar-id the patient hadnot been referred for treatment until several days after injury. In six instances,

operation was delayed because associated injuries did not permit early surgery.

SURGERY

Surgery, in all cases, consisted in primary triple arthrodesis (talocalcaneal,talonavicular, and calcaneocuboid). In no instance was there an attempt to reduce


or itnprove fracture alignment by closed procedures. The operation is perfortmcd,

usitmg tourniquet control, with the patient inclined to the opposite side. Thehip and knee are flexed approximately 30 to 40 (leglees; the leg, ankle, at-id inner

foot are placed on a sandbag so that the heel extends over the edge into yams

position. The skin incision is of at-i Oilier type, which extetmds from the regionof the lateral border of the extensor tendoum mmear the talonavicular joint, transect-itig the sinus tarsi and continuing posterior to an area an inch inferior to the

external malleolus. The skin is reflected with the underlying soft tissue andshould not be undermined. The origin of the short extensor muscle is thenreflected distally, and the sinus tarsi is entered. The dissection is extended to

expose the calcaneocuboid joint, the talonavicular joint, and the talocalcaneal

joitt. The extent of the fracture of the calcaneus is then observed.Itm each instance an attempt was made to accurately tabulate the findings at

surgery, with particular reference to the fracture of the cuboidarticular� surfacearid of the subtalar joint. In some instances the peroneal tendon sheath wasopened and the tendon reflected, in order to better expose and visualize the cx-tent of the fracture. Frequently, the anterior process of the calcaneus was frac-tured and displaced. Whether fractured or not, it is removed, and the calcaneo-cuboid joint is resected. The capsule of the talonavicular joint is opened, and

exposure is facilitated by stripping the capsule on its medial aspect with a Hattspoon. This joint is then removed, and the subtalar joint is excised. This canbe facilitated by removing the anterior margin of the posterior calcaneal articularsurface of the talus which projects downward and anteriorly and somewhat ob-scures the joint. The cartilaginous surface of the talus is first removed, affordingbetter visualization of the articular surface of the calcaneus and its comminutedpieces. Small, loose fragments are removed, and their articular surfaces aredenuded before they are replaced. The depressed articular surfaces are elevatedby means of an osteotome, which is placed between or beneath them. Manual lat-

era! and medial compression helps to stabilize their position. Control of thefragments temporarily can be secured by means of a Kirschner or threaded wire

introduced through the lateral cortex to facilitate denuding of the articular

area. Removal of the cartilage from the middle articular surface is facilitated bymeans of stabilization with a pin inserted from the medial aspect of the foot.

General reduction and apposition of the denuded surfaces are accomplished underdirect vision. In most instances a staple is used to secure the calcaneocuboid

joint (Fig. 1 1). The lateral fragment is manually compressed to eliminate anylateral piling up. A Kirschner wire is then inserted through the heel pad intothe lateral fragment or cortex to prevent recurrence of lateral spread and to secureit soundly to the talus. In some instances a second staple has been placed from

the lateral border of the calcaneus into the talus to prevent recurrence of lateraldisplacement (Fig. 5-B). Pin fixation has been utilized, as deemed necessary,to properly secure apposition of the denuded surfaces, as Caldwell recommendsfor triple arthrodesis. Occasionally, a second wire has been placed through theheel pad into the medial fragment of the calcaneus to secure it when there haspersisted a tendency for it to be displaced. It has been found that contact, align-ment, and stability are accomplished by the use of staples and Kirschner wires

or pins. The extensor-muscle origins are replaced, and soft tissue is reapproxi-mated. A leg plaster cast is applied, incorporating the plantar wires or pins, and

the tourniquet is then released.

POSTOPERATIVE MANAGEMENT

The care after surgery is as usual for a triple arthrodesis, including properelevation of the leg. The degree of comfort encountered, after the first twenty-four to forty-eight hours, in patients who undergo triple arthrodesis early is sur-prising when compared with that in patients whose associated injury necessitates

delay. The patient is usually allowed up in a wheel chair on the third or fourthpostoperative day, and walks with crutches on the seventh to tenth postoperative



day. The plaster cast is changed, with wire removal, during the fourth or fifthweek. Weight-bearing in a plaster cast is started at eight weeks, and, three to

four weeks later, the plaster cast is removed and physical therapy to the ankleis instituted. The patiet-it is either fitted with a leg brace or high-top shoe, andweight-bearimmg with crutches is started.

OPERATIVE FINDINGS

The extent of the fracture, as noted when surgically exposed, was somewhatconsistent with the roentgenographic immterpretation of the injury; almost uni-

formly, however, the severity of the fracture was found to be greater than sus-pected. The appearance of the fracture was scrutinized in all roemmtgenograms priorto surgery, arid at-i attempt was made to determine whether the fracture itmvolvedthe cuboid articular surface. This itivolvement was showim l)y roentget-iogram intwetity-five fractures and was verified in all of them at the tin-ic of operation. The

involvement of the subtalar joitt by the fracture was always found to be immre

extensive that was anticipated from the roentgemographic evaluatiom-i. Frequettly,small, comrninuted, detached, articular fragments were foutmd which, im son-icinstances, had beet-i driven deep into the cancellous area. With fracture of the

sustentaculum tali and associated longitudinal split it-i the posterior articular

surface, the two articular surfaces formed a V, with fragments which had beetidriven down below the articular level. It was impossible to properly replace son-icof the smaller comminuted fragments, and it seems impossible to accomplish ana-tomical reduction of such a joint by closed or open procedure. The subluxation of

the talus at the talonavicular joint was noted in some of the more severe injuries,

but not with the frequency with which the fracture involved the cuhoid articular

surface.

ANALYSIS OF CASES

The data for the patients under study are presented in Table I and Table II.In order to reflect more precisely the result of primary triple arthrodesis, thesepatients have been divided into two groups : those without associated inj ury(Table I) and those with associated injury (Table II). The ages of the twenty-five patients treated ranged from’ twenty to sixty years, with an average of 41.4years. Twenty-four patients were male; one was female. In Table I are included

patients 5, 8, and 10 who had bilateral fracture of the calcaneus; Patient 5 had

bilateral comminuted fractures; Patient 8 and Patient 10 had undisplaced frac-

tures of the left calcaneus, which did not involve either the subtalar or calcaneo-cuboid joint and did not require operative treatment.

Of the twenty-six primary triple arthrodeses which were done, sixteen wereon the right and ten were on the left. Twenty-one of these patients were laborers;fifteen of them had competsable injuries. Three other patients had injuries which

involved liability claims.The associated injuries, as listed im Table II, were those of: Patient I , who

had fracture of the second lumbar vertebra; Patietmt 2, who had commitmuted frac-ture of the mid-shaft of the right humerus; Patient 3, who had fracture-dislocatiommof the left humeral head; Patient 4, who had multiple fractures involvimmg the pelviswith acetabular displacement and a compound, comminuted fracture of the mid-

shaft of the right femur; Patient 5, who had supracondylar fracture of the rightfemur and bimalleolar fracture of the right ankle; and Patient 6, who had an

extensive comminuted fracture of the right tibia, involving the ankle joint, withdisplacememmt, necessitating ankle fusion.

RESULTS

r� he patients reviewed iimclude all those on whom a primnary triple arthrodesis

was performed from 1948 through 1956. The duration of follow-up ranged fromsix months to more than nine years, with an average follow-up of 3.8 years.

Healing time of the triple arthrodesis, as judged roentgenographica!ly by



restoration of trabeculae across the arthrodesed joints, averaged 3.2 months.

Those patients without major associated injury returned to work on an averageof six months after surgery, whereas those with associated injury required an

average of eight months before returning to work. All patients returned to theirformer employment. The average time after surgery at which the twenty-fivepatients went back to work was 6. 5 months. The average time at which thetwelve patietits with compensable injuries without associated injury returnedto work was 5.3 months, whereas those of this group who did not sustain industrialinjury returned to work in 7.3 months.

There was one complication, consisting of drainage, which began approxi-mately six weeks after operation ; culture and smear were negative. A staple at thecalcaneocuboid joint was removed approximately four months after surgery, butminimum drainage persisted. Sequestrectorny of a bone fragment at the calcaneo-cuboid joint was performed approximately eighteen months after triple arthrod-esis. This patient died two and one-half years after his injury from a ruptureof am-i aneurysm in the circle of Willis; prior to his death, healing had occurred.Roentgenographically, this patient had a pseudarthrosis of the calcaneocuboidjoint, resulting from sequestration of a fragment of bone at this joint. A pseud-

arthrosis at the talonavicular joint developed in another patient, but neitherof these patients had symptoms referable to their pseudarthroses.

Twenty-one patients (84 per cent) were rated as having obtained excellentresults. These were those who returned to their former occupations with no pain

arid no restriction of their activities. The loss of inversion and eversion whichresulted from the primary triple arthrodesis was not considered by the patientsto restrict ammy activity which they wished to perform. There was no detectable

alteration in gait. Three patients (12 per cent) were rated as having obtainedgood results; they returned to their former occupations and had no serious in-terference with their activities although they all had a mild limp, mild discomfort,

or some minor complaint. One patient was rated as having a fair result becauseof postoperative drainage; he, however, experienced no pain or restriction ofphysical activity and he walked with a normal gait. In some feet there wasresidual broadening of the heel, which has not, however, produced any functionalimpairment or symptoms.

In two patients with long-term follow-up, an exostosis developed on thedorsal aspect of the neck of the talus. This occurred in one of the feet of thepatient who had had bilateral primary triple arthrodesis. Whether this conditionresults from the injury or from some other cause is not known. There was no sig-nificant impairment of ankle motion except in the one instance of an exostosis,

as just described, in which there was 10 degrees of restriction of dorsiflexion.An interesting observation was made in two patients who had had bilateral

fractures of the calcaneus which were treated by a primary triple arthrodesis for thecomminuted fracture on one side and by a short period of immobilization in aplaster cast for the undisplaced fracture on the other side. When re-evaluated,four and one-half and five years later, respectively, both patients stated that thefoot treated by triple arthrodesis was more comfortable than the other foot.

CONCLUSION

From this study it has been found that the severe, comminuted, displacedcalcaneal fracture is associated with involvement of the two peritalar jointsconsisting of fracture of the articular surface of the calcaneus at the calcaneo-cuboid joint Wand, in some instances, associated subluxation of the talar head atthe talonavicular joint. The conventional projections are not adequate for the

roentgenographic examination of the comminuted, displaced, fractured calcaneus,

and two additional projections as described are necessary. Involvement of the twoperitalar joints affords an explanation for some of the unsatisfactory results re-ported in the past. We believe that the injury to the talocalcaneal joint is irrep-arable and that fusion of this weight-bearing joint is necessary. The associated



injuries of the two peritalar joints similarly prevent the restoration of their

normal functiomm. It’ has been our experience that triple arthrodesis as the initialprimary treatment of timese fractures has given extremely gratifying results.

REFERENCES

1. ALLAN, J. H. : The Open Reductiolm of Fractures of the Os Calcis. Ann. Surg., 141 : 890-900,1955.

2. ALLISON, NATHANIEL: Timirtieth Report of Progress in Orthopedic Surgery. Arch. Surg., 13:

445-458, 1926.r 3. ALLIsoN, NATHANIEL: Thirtietim Report of Progress in Orthopedic Surgery (cont’d). Arch.p Surg., 13: 605-614, 1926.

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, 5. B�RARD atl(l MALLET-GUY: A propos do traitenment sanglant des fractures r#{233}centesdu cal-can#{233}um. Lyon Chir., 26: 453-456, 1929.

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8. CALDWELL, C. A. : Arthrodeses of the Feet. In Instructional Course Lectures, The AmericanAcademy of Orthopaedic Surgeons, 1949. Vol. 6, pp. 17-1-177. Ann Ari)or, J. \V. E(Iwards,1949.

9. CLARK, LE GRos: Fracture of the ( )s Calcis. Latmcet, 1 : -103-404, 1855.10. Coxs, H. R. : Fractures of time Os Calcis. In Irmstriictiotmal Course Lectures oti Itecormstrtictive

Surgery of the Extremities, Time American Academy of Orthopaedie Surgeons, 19.14, PP 137-147. Ann Arbor, J. \V. FAlwards, 1946.

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917-918, 1921.15. Co’r’rox, F. J., armd H:N1�:Rsox, F. F. : Results of Fractures of the Os Calcis. Atim. J. Orthop.

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559-565, 1908.17. DESFOSSES: Cited by (ioff.18. DICK, I. L. : Prin�ary Fitsioti of time Posterior Sul)talar Joint iii time Treatnment of Fractures of

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VOL. 41-A. NO. 8. DECEMBER t959


:39. THOMPSON, M. S., and HUGHES, F. H., JR. : Open Treatment of Os Calcis Fractures. Med. Btmll.U. S. Army Europe, 13: 267-268, 1956.

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44. WILMOTH, P., and LECOEUR, P. : Le traitement op#{233}ratoire des fractures sous-thalamiques dimcalcan#{233}um. Reduction sanglante et greffes osseuses. J. de Chir., 33: 781-792, 1929.

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DISCUSSION

DR. JOHN HAMILTON ALLAN, CHARLOrFESYILLE, VIRGINIA: Fractures of the caicaneus con-

tinue to remain the most disabling of all industrial injuries. One reason for this is that poor endresults have been obtained by the various methods of closed reduction, and the discouraged sur-geon, not caring to do arthrodesis or an open reduction, has concluded that simple immobilization

is as good as any form of treatment.There are several observations made in this paper which deserve emphasis:

1. It is imperative not to neglect this fracture, but to treat it early and definitively in order toprevent disability.

2. Comminuted fractures of the calcaneus cannot be treated successfully by any of the closed

manipulative procedures.3. Multiple roentgenograms projected as described are essential to reveal the major fracture

lines and to determine whether the calcaneocuboid and talonavicular joints are involved. Theextent of the fracture damage is always much greater when visualized directly than it is in theroentgenogram.

4. The calcaneocuboid joint is involved in so many of these fractures that, as a general prin-ciple, the results with arthrodesis are somewhat better than they are with subtalar fusion.

Finally, in the technique of their operation the authors state that reduction and appositionof the fractured surfaces are accomplished under direct vision. This is of significance because it is

an accepted orthopaedic principle that joints should be fused in their normal anatomical andfunctional position. When applied to the comminuted displaced calcaneus, this means that thetuberosity must be pulled down, the posterior articular facet elevated to its normal position, and

the lateral spread corrected at the time of the fusion so that a good functional position of the foot

is retained.

In one respect our experience with these fractures does not agree completely with that of theauthors. This paper deals with comminuted fractures involving the subastragalar joint, and theclassification includes those with centrolateral depression of the joint. The authors stated that thesefractures all exhibit extension forward into the cuboid articular surface. It is agreed that when thefracture line disrupts the calcaneocuboid joint, arthrodesis is indicated. However, there are many

fractures of the caicaneus which present primary or secondary depression of the posterior articular

facet and which do not extend forward into the calcaneocuboid joint. These are the ones whichrespond beautifully to an open reduction, elevation of the posterior articular facet, and insertionof a bone graft into the compression cavity as described by Palmer. Some lateral motion throughthe foot should be preserved if possible.

I must conclude, therefore, that most comminuted fractures of the calcaneus will require thetreatment advocated in this paper. However, the treatment must be designed to fit the patternof the fracture, and, in many carefully selected cases, open reduction and retention of the reductionby the Palmer technique will give an excellent result and preserve the lateral motion through thefoot.


calcaneal fracture treatment by primary arthrodesis

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