Injury, Int. J. Care Injured (2004) 35, S-B46—S-B54

Calcaneal fractures—open reduction and internal

fixation (ORIF)

Hans Zwipp, Stefan Rammelt, Sven Barthel

Trauma Department of the University Hospital of Dresden, 01307 Dresden, Germany

KEYWORDS:

Calcaneus; fractures;

fracture dislocations;

compartment syn

drome; open reduc

tion; internal fixation;

interlocking plate.

Summary1 Although pioneers such as Leriche in 1921 [5] and Judet et al in 1954

[4] introduced screw or plate fixation of the broken calcaneus, surgical treat-

ment using open anatomical reduction and stable internal osteosynthesis only

commenced at the start of the 1980s. This treatment was made possible by the

introduction of new imaging methods such as CT which allowed better detection

of the fracture pathology and provided the basis for new surgical strategies. Since

the start of the 1990s, various anatomically shaped steel and titanium calcaneal

plates have been available. The Foot and Ankle Expert Group of the AO Founda

tion together with Synthes USA developed an anatomically shaped interlocking

calcaneal plate, which has been available in steel since 2002, and a titanium-

molybdenum (15%) alloy version (Mathys) since November 2003. The latter is now

being tested clinically in our unit.

Indications for surgery

The principal aims of treatment are:

1. Restoration of height, length, width, and axis of the calcaneus.

2. Anatomical reconstruction of all joint surfaces. 3. Restoration of function by primary stable osteo-

synthesis.

Open reduction and stable internal fixation to permit functional aftertreatment is necessary in all intra-articular fractures with relevant joint displacement (> 1 mm) and in all extra-articular fractures compromising the soft tissues and/or with unacceptable positioning, shortening, and broaden-ing of the calcaneus (> 10° valgus / > 5° varus) if

the fracture cannot be fixed by closed reduction and percutaneous screwing.

Emergency cases for ORIF are open fractures, closed fractures with acute compartment syndrome, articular fracture dislocations and extra-articular fractures with incarceration of the soft tissues. In cases associated with polytrauma, local debride-ment of open fractures, retrograde Redon drainage in closed fractures with severe hematoma, and a medial insertion of a temporary triangular external fixator are performed.

Surgical procedure

Fixation devices

Various devices can be used for internal fixation of calcaneal fractures. We prefer 3.5 and 2.7 mm cortical screws if buttressing is not needed. In solid

1 Abstracts in German, French, Italian, Spanish, Japanese,

and Russian are printed at the end of this supplement.

0020–1383/$ — see front matter � 2004 Published by Elsevier Ltd.doi:10.1016/j.injury.2004.07.011

Calcaneal fractures: Open reduction and internal fixation S-B47

4- to 5-fragment cases, we use the very flat (1.0 mm) so called AO “Sanders plate”, made of titanium, to have the postoperative option of CT-control. In com-minuted fractures, severely subthalamic impacted fragments, and osteoporotic bone, we use the new interlocking calcaneal plate, preferably in the tita-nium molyden version.

Approaches and surgical techniques

We use four different isolated or combined surgical approaches:

• The extended lateral approach (Seattle).• The medial approach (modified Mc Reynolds). • The sustentacular approach.• The lateral approach (modified Palmer).

Extended lateral approach (Seattle approach)This standard approach is most useful in the very common B2 intra-articular calcaneal fractures since we know that the posterior facet is fractured in more than 90% of these cases and the cuboidal facet in almost 60% [10].

The patient is placed in a lateral decubitus posi-tion on the noninjured side on a radiolucent op-erating table allowing intraoperative fluoroscopy, arthroscopy, and x-ray control.

The skin incision is L-shaped over the lateral aspect of the heel, running between the lateral malleolus and the posterior and inferior border of the heel (Fig. 1). With respect to the blood supply to the lateral aspect of the heel via the lateral calcaneal artery and the course of the sural nerve [2, 3], the incision is not placed exactly halfway between the lateral malleolus and the foot edge, but directed more towards the sole and the border of the Achilles tendon [8]. The approach is exercised in the fashion of a full-thickness flap [1]. The peroneal tendons should not to be seen except in the area

of the peroneal tubercle, where a medial sheath is missing. Distally, the peroneal tendons have to be mobilized within their sheaths for exposure of the calcaneo-cuboidal joint. The fibulo-calcaneal liga-ment is detached from the bone and all preparation is epiperiostal. Generally, no sharp hooks are used. As soon as the subtalar joint has been visualized, three 2.0 K-wires are introduced close to the joint into the talar body and neck, and a fourth into the cuboid if exposure of the calcaneo-cuboidal joint is needed. After a good view into the subtalar joint, we start reducing the posterior facet. If the medial part of posterior facet is not congruent with the talus (Fig. 2), we have to reduce this sustentacular fragment so it is congruent with the talus, keeping it temporarily reduced with a 2.0 K-wire coming from the plantar side, fixing the reduced susten-tacular fragment to the talus. After this procedure, an intermediate posterior facet fragment will be reduced and fixed temporarily with a K-wire that runs from laterally through the skin medially. It is retracted so far medially that we can reduce the larger lateral part of the posterior facet congruent with the medial part of the posterior facet and the talus by temporarily fixing the subtalar joint in an anatomical position by running a K-wire back from medial to lateral. After this maneuver, we reduce the tuberosity fragment and the anterior process fragment, keeping them in a reduced position with K-wires. After anatomical reduction, the interlock-ing plate is modeled and applied to the calcaneal

Fig. 1: Extended lateral approach.

Fig. 2: Reduction maneuver in a case of a tilted susten-tacular fragment and additional intermediate fragment. 1 = first K-wire to fix the reduced sustentacular frag-ment. 2, 3 = second and third K-wire, which fixed the intermediate fragment first, lateral to medial, through the skin just withdrawing it backwards to the level of the lateral side of the intermediate fragment surface. After anatomical reduction of the lateral part of the posterior facet towards the intermediate fragment, the K-wires are drilled back, medial to lateral, just to have all three fragments of the subtalar joint area temporarily fixed with K-wires.

S-B48 H. Zwipp et al

Fig. 3: B2-fracture of the calcaneus fixed with the inter-locking calcaneal plate. (a) The lateral view and the Brodén’s view show the deep impaction of the posterior facet. (b) The axial and coronal cut of the CT-scan show the severe damage to the calcaneo-cuboidal and subtalar joint classified according to the new AO-Classification as 81.2 B2 [d,h(1.3.3)]. 81.2 = calcaneus, B2 = intra-articu-lar fracture of two joints involved, d = posterior facet, h = cuboidal facet, 1.3.3. = bony lesion, multifragmentary, severely dislocated. (c) Intraoperative situs after anatomical reduction and fixation with the interlocking plate. 1 = one of the four 2.0 K-wires, which are inserted in the talus and cuboid keeping the full thickness flap upwards for optimal expo-sure. 2 = tab bowed close to the bone in the calcaneal neck area to keep the anterior process fragment in ana-tomical position. 3 = tab bowed towards to the bone, which might keep a plantar triangular fragment in posi-tion. 4 = 2.0 mini screw fixing the lateral part of the posterior facet which was broken in itself. 5 = one of the interlocking screws, here close to the calceneo-cuboidal joint. 6 = 3.5 screw which has to be inserted as a com-pression screw at the very beginning not to leave a gap in the subtalar joint. (d) Anatomical reduction and fixation with the interlock-ing calcaneal plate.

Calcaneal fractures: Open reduction and internal fixation S-B49

wall. The tab over the calcaneal neck (Fig. 3) is precisely bowed with special forceps. Six screws are usually placed into the calcaneal bone: Two from the subthalamic area into the sustentaculum, two into the tuberosity fragment far dorsally, and two screws into the anterior process fragment close to the calcaneo-cuboidal joint. The very first subtha-lamic screw should not be an interlocking screw but a 3.5 compression screw so as not to leave a gap in the posterior facet.

Sustentacular approachThis small medial approach minimizes the haz-ards of neurovascular damage as compared to the McReynolds approach, but is only useful in isolated sustentacular fractures and as a supplement to the extended lateral approach in complex intra-articular

fractures with fragmentation of the sustentaculum at the medial joint facet. The 3—5 cm incision runs horizontally directly over the palpable sustentacu-lum that lies about 2 cm below and 1 cm anterior to the tip of the medial malleolus (Fig. 4). The nearby tendons of the posterior tibial, the flexor digitorum longus and the flexor hallucis longus muscles are identified and held away with a penrose drain for exposure. After controlling the medial joint facet, reducing it, and fixing it with 2.0 screws if broken in itself, the sustentaculum is usually fixed with long 3.5 compression screws, which are introduced in a declined direction into the calcaneal body in order not to hit the posterior facet. This procedure is performed very easily using percutaneous forceps, which are under development by the AO Foot and Ankle Expert Group (Fig. 5).

Fig. 4: Sustentacular approach. (a) Incision line just over the sustentaculum. (b) Reduction and screw fixation of the comminuted sustentacular main fragment. (c) The tendons around the medial facet are retracted for joint exposure. (d) Reduced situs of the multifragmented sustentacular area.

Fig. 5: Minimal invasive procedure in the case of an isolated sustentacular fracture reducing and fixing it with percu-taneous forceps, which is still under development.

S-B50 H. Zwipp et al

Fig. 6: Severe fracture dislocation of the calcaneus in a 28-year-old male falling from a stair. a) Severe dislocation of the tuberosity completely below the lateral malleolus with blowing it out. Severe com-minution of the anterior part of the calcaneus into the calcaneo-cuboidal joint. b) The dorso-plantar x-ray and the CT-cuts show impres-sively the dislocated tuberosity with the main part of the

posterior facet. Comminution of the distal fibula and the anterior half of the calcaneus involving the medial and cuboidal facets. c) Modified Palmer approach for exposure of the poste-rior facet, the calcaneo-cuboidal joint, and the distal fibula as well (left above). Bending of the plate with the threaded tab benders (right above). Smooth cutting of the plate with a special cutting forceps (below).

Calcaneal fractures: Open reduction and internal fixation S-B51

Medial approach (modified McReynolds)The medial approach according to McReynolds [6] only allows reduction of the main fragments but no control over the joint congruency of the posterior facet. It is useful in simple extra-articular fractures or in combination with a lateral approach in cases of severe fracture dislocation (Fig. 6). The incision is made horizontally or as a lazy S cut about 8—10 cm exactly halfway between the tip of the medial malleolus and the sole. The neurovascular bundle is identified and carefully held away with a pen-rose drain. The abductor hallucis longus muscle is retracted downwards, whereas the flexor hallucis longus tendon is only identified and left in place. The sustentacular fragment of the calcaneus can be fully visualized and the medial facet controlled only indirectly. The tuberosity fragment is reduced indirectly under axial pull against the sustentacular fragment and the anterior process, if separated from the main tuberosity fragment. After temporary K-wire transfixation, definite fixation is achieved

with a small H-plate or with two interlocking holes cut from the interlocking plate (see Fig. 6 c—e) with the well known antiglide principle.

Lateral approach (modified Palmer)This approach is modified by extending the incision more cranially over the distal fibula. It is suitable in the rare cases of a severe fracture dislocation where exposure of the lateral malleolus is also needed (see Fig. 6a).

Defect filling and plate design

Since we have been using the interlocking calca-neal plate we generally do not use cancellous bone grafting, even in cases with large defects below the reduced posterior facet.

Intraoperative controls

In intraoperative x-ray control we perform a lateral view of the foot, a dorso-plantar view, a Harris view, and a Brodén’s view with the tube tilted 20°. If there

d), e): Anatomical reduction of the posterior facet, the cuboidal facet and the fibula approached bilaterally by using cut parts of the interlocking plate laterally with six holes and medially with two holes. By means of the antiglide principle, a solid primary stability is achieved.

S-B52 H. Zwipp et al

is any doubt about the congruency of the posterior facet, we do an open subtalar arthroscopy (Fig. 7). A small arthroscope is introduced into the exposed subtalar joint producing varus stress to the calcaneus with the inserted Schanz screw. If a residual step off is seen, the subthalamic screws are removed and joint reduction is repeated replacing the subtalar screws in the corrected position.

If there is severe bleeding from the cancellous bone before skin closure, we cover this area with a collagen sponge. We always use a Redon drain, size 8—10 Ch. After applying a sterile dressing, a split lower leg cast is attached, only for the period of wound healing.

Postoperative care

Postoperative rehabilitation aims at early mobili-zation of the patient irrespective of the surgical approach. The protocol includes active and passive range of motion exercise in the ankle, subtalar and Chopart’s joints, and isotonic and isometric exer-cises of the leg combined with continuous passive motion, beginning on the second postoperative day. Patients are restricted to partial weight bearing in their own shoes for 6—12 weeks, depending on the severity of the fracture. Using the interlocking plate, full weight bearing can be allowed an average of three weeks earlier than in other cases. Hardware removal, approximately one year after placement of a lateral plate, is optional. Since postoperative adhesion and arthrofibrosis are seen in about 20—25% of our cases, this procedure is combined with a subtalar arthroscopy and arthrolysis, including

intra- and extra-articular debridement of the sub-talar joint [7]. Arthroscopic grading of the subtalar joint quality is closely correlated with the clinical results and helpful in decision-making for subtalar arthrodesis [8].

Patients

Between October 1993 and August 2003, a total of 496 patients with 553 calcaneal fractures were treated at the Traumatology Department of the University Hospital “Carl Gustav Carus” Dresden. 57 patients had bilateral calcaneal fractures (11.5%), the mean age was 41.7 years (12—75 y). The gender was male in 387 cases (78%) and female in 109 cases (22%). CT-scanning in two planes in 553 calcaneal fractures showed intra-articular involvement of the posterior facet in 86.2% and also of the cuboidal facet in 59.7%. An open fracture was seen in 10.2%, a third degree closed fracture with acute compart-ment syndrome in 5.5%. 22.2% of the patients were polytraumatized. Surgery was performed in 89.6% using an extended lateral approach in 95.3%, a bilat-eral approach in 1.5%, and a single medial approach in 1.0%. Percutaneous procedures were done in 2.2% and a primary fusion in 0.4%. Surgery was performed on an average of 8.8 days after trauma (0—23 d). In 350 cases (77.3%), a Sanders titanium plate was used, 28 cases (6.2%) had an H-plate, and in 22 cases (4.8%) only screws were applied. During the last two years an interlocking calcaneal plate was used in 53 cases (11.7%). Additional autologous bone grafting was done in 53% of fractures treated with a Sand-ers plate and in 3.8% of fractures treated with an

Fig. 7: Intraoperative open arthroscopy of the subtalar joint. (a—c) Show the step off of the posterior facet. (d, e) Absolute ana-tomical reduction after repeated correc-tion of the posterior facet fragment dem-onstrating the advantage of arthroscopic control.

Calcaneal fractures: Open reduction and internal fixation S-B53

interlocking plate, which is a dramatic reduction in the use of bone graft. Analyzing the early postopera-tive complications in 453 cases of ORIF, we found wound edge necrosis in 6.7%, hematoma to evacu-ate in 4.7%, soft tissue infection in 4.3%, and bone infection in 2.2%. Non-union was only seen in 0.4%, a secondary amputation did not occur in any case despite 10.2% of all cases having open fractures. This finding might be due having performed an early free flap in every fifth case of an open fracture. Looking at the 5-year follow-up in 194 cases according to the Merle d’Aubigné-Score, we saw excellent results in 46%, good results in 42%, and only 11% fair and 1% poor results. According to our ± 200 point score, we had excellent results in 11%, good results in 61%, fair results in 25%, and poor results in 3%, observing a secondary fusion rate of the subtalar joint in 5.6% related to the 5-year follow-up.

Summary and conclusions

Analyzing more than 500 cases of calcaneal fractures at our department over the last ten years we can conclude:

1. Patients with clear indications for ORIF doubt-lessly benefit from this procedure using indi-vidually tailored approaches, implants, and fixation techniques.

2. Very precise indications and contraindications are necessary as mentioned initially to minimize risks for the patient.

3. In cases of high risk for ORIF, a primary functional treatment is performed and a secondary bone block subtalar fusion is done about one year later, if necessary.

4. In cases of severe fracture dislocations, even in high risk patients, a minimum of reduction has to be performed to avoid the need for osteotomy after severe malunion because bone block fusion with additional osteotomy is a very demanding procedure with an uncertain outcome.

5. Third degree closed fractures with acute compartment syndrome are cases for urgent ORIF. Using an extended lateral approach with evacuating the medial and lateral hematoma, and performing definite plate or screw fixation, wound healing and function can be seen without any sequelae of compartment syndrome.

6. To prevent soft tissue and/or bone infection in cases of second to third degree open or closed fractures with full thickness skin necrosis, an early free flap should be done within the first five days of trauma.

7. In polytrauma patients with open fractures or closed fractures with compartment syndrome, a debridement or a minimal-invasive evacuation of the hematoma with a retrograde inserted Redon drain is indicated. Temporary artificial skin graft or vacuum closure in addition to a triangular, medially inserted external fixator is highly recommended.

8. In cases of polytrauma with a calcaneal fracture of one side, the use of screening CT-scanning is recommended to prevent overlooking a clinical-ly secret isolated fracture of the sustentaculum of the contralateral side as was seen in three of our own cases.

9. Using the interlocking calcaneal plate, cancel-lous bone grafting does not seem to be neces-sary. Full weight bearing appears to be possible three weeks earlier than in other types of fixation.

10. If an intraoperative open arthroscopy was not performed to prove the anatomic reduction of the subtalar joint, a postoperative CT-scan should be performed for quality control.

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Correspondence address:

Hans Zwipp, MDProfessor of TraumatologyTrauma Department of the University Hospital of DresdenFetscherstraße 4701307 Dresden, Germanyemail: uwch@uniklinikum-dresden.de