Operative v Nonoperative Literature
1. Buckley etal JBJS Am 2002
Prospective multi-centred RCT
- 309 displaced intra-articular fractures
- operative v non operative management
- 2 year follow up
Findings
- used patient orientated functional outcomes
- overall VAS and SF36 not significantly different between 2 groups
Improved Operative Outcome if
- not workers compensation
- women
- < 29
- bohler's angle 0 - 14 initially (not -56 to -1)
- light workload (not heavy manual worker)
- anatomical reduction < 2mm (CT of post facet)
- type 2 sanders (types 3 and 4 did not)
Note:
Any patient who required a subtalar arthrodesis to relieve pain was removed from the study.
A non operatively treated patient was 5.5 x more likely to need this operation!
Complications
- 5% deep infection
- 17% superficial infection
- STJ arthrodesis: non operative 17%, operative 3%
2. Sanders 1993
Heel shape restored in 98+%
- Type II - 85% reduction and 75% good results
- Type III - 60% reduction and 70% good results
- Type IV - no anatomical reduction and 10% good results
Conclusion:
Sanders classification gives guide of prognosis
Once posterior facet is in more than 3 parts, good outcome decreases drastically
3. Stulik etal JBJS Br 2006
287 displaced intra-articular fractures
- 1 year follow up
- Sanders 2, 3, 4
Any patient excluded from ORIF but amenable to OT
- DM / smokers / vascular insufficiency / compound wound / severe fracture blisters
Treatment
- MUA & Gissane spike percutanous reduction
- additional K wires
Results
- 16.5% excellent, 55.7% good
- 14.8% fair and 13% poor
- Sanders 2 > 4
Complications
- 1.7% deep infection
- 7% superficial infection
- nil amputation
Conclusion:
There are intermediate options between ORIF and non operative
- with the ability to somewhat restore heel height and width
- in high risk patients who cannot have ORIF
- probably makes subsequent fusion easier
4. Poeze et al JBJS Am 2008
Calcaneal volume load v outcome
- centres with higher volume load
- reduced rates of deep infection and subsequent subtalar arthrodesis
5. Heller JBJS Am 2003
43 compound calcaneal fractures
- wound usually medial
Type I ORIF
- no infections in 7/7
Type II
- 3/8 infection
Type IIIA
- 3/12 infection
Type IIIB
- 10 /13 infection
- 6 /13 became deep osteomyelitis
- 3 required amputation
Conclusion
- very dangerous to ORIF anything other than Type I compound fracture
- a quarter to a third of type II and IIIA will get a deep infection
- absolutely not in any patient who will need a flap
6. Folk et al JOT 1999
If patient had DM + PVD + smoker, wound problem rates > 90%
5. Rodger Atkins AOA 2000
Salvage arthrodesis very difficult
- always better to attempt reconstruction initially even if just to make arthrodesis easier
- alternative is Primary Arthrodesis
6. Wei et al. Medicine 2017
Meta-analyis of operative v non operative for displaced intra-articular fractures
- 8 RCTs, 10 controlled trials, 1467 patients
- 4 studies used AFOS outcome measure, with no difference
- no significant difference in pain or shoe wearing
- operative group more likely to return to work
- complication rate of 26% in the operative group, significanlty higher
https://pubmed.ncbi.nlm.nih.gov/29245290/
Management
Aims
Pain free functional foot that can fit in a shoe
Goals
1. Restore heel shape (height, length and width)
2. Reduce joint surface
Options
1. Non-operative
2. ORIF
3. Primary STJ arthrodesis
4. Salvage / STJ arthrodesis
Issues
1. Patient factors
Smoking
- higher incidence infection
- try to get them to stop
DM, PVD
- high risk of infection
Heavy manual workers
- will find it difficult to return to work
Bilateral fractures
- do worse
Gender
- women do better
Age
- younger do best
2. Soft tissue envelope
Compound fractures
- wound medial
- operative for Type 1
3. Fracture type
Bohler's angle
- if less than 0o initially, do poorly however managed
Sander's
- prognostic (type I do well, type IV high rates fusion)
- lateral wall fragments easier to fix (2A)
- very medial fractures (2C) very difficult
Assess
- Bohler's angle
- Posterior facet / Sanders
- CCJ joint
- lateral wall fragment
- sustentaculum fragment
- tuberosity / heel in valgus
4. Surgeons experience
Non Operative Management
Indications
- non displaced
- Bohler's > 20
- Sanders IV
- DM, PVD
- compound fracture Type 2 & 3
Technique
- elevate +++
- POP
- NWB 6/52
- Then progressive WB
Complications
- STJ OA
- peroneal impingement or subluxation
- calcaneocuboid arthritis
- malunion of hindfoot
- posterior tibial nerve entrapment
- difficulty with show wear
Operative
Indications
- healthy patient
- ? smoking
- Saunders II / III
- Bohler's < 20o
- displaced tongue type fractures
Contra-Indications
- severely comminuted sustentaculum tali
- type IV
Needs to be an individualised approach with risk stratification
Initial
- Bed rest, elevation, ice & compression till skin wrinkles evident
- between 1 week and 4 weeks
Blisters
- clear fluid (some epidermis attached to dermis)
- bloody fluid (no epidermis attached to dermis)
- shown that there is some increased risk of wound problems if incision passes through blisters
1. ORIF
Technique
Position
- patient on side, blankets under foot
- operated foot up
- radiolucent table, II available
- GA, IV Abx, tourniquet
Incision
- extensile lateral approach
- behind posterior edge of fibula
- anterior to T Achilles
- sural nerve posteriorly in flap
- along borders of calcaneum (Abd H below)
- keep distal cut along inferior margin calcaneum
- angle up towards CCJ
Superficial dissection
- elevate full thickness flap with peroneal tendons
- down to bone
- divide CFL
- K wires to retract skin flap
- 2 in talus / 1 in fibula
- expose CCJ
Bleeding
- calcaneal artery
- branch of peroneal artery
Steinmann pin to tuberosity
- through heel skin
- can elevate and pull out of varus
Hinge lateral wall fragment
- opens on posterior / inferior periosteum
- gives access to subtalar joint
- if type 2C may need lateral wall osteotomy
- divide interosseous ligament
- homan or lamina spreader to expose STJ
ORIF
- Reduce medial fragments and work laterally
1. Restore posterior facet with screws
2. Restore calcaneum height and Bohler's by reducing tuberosity fragment
3. Pull out of varus
4. Reduce posterior facet & lateral joint fragment onto sustentaculum fragment
- golden screw
- 3.5 mm screw
- aimed anteriorly, medially and slightly upwards
5. Elevate anterior process fragment
6. Locking contoured plate
Intra-operative II
- lateral
- Broden's view
Closure
- careful haemostasis
- closure over drain
- elevate +++ for one week
Post op
- NWB 12 weeks
- early ROM exercises once wound healed (2-4 weeks)
2. Essex-Lopresti closed reduction and percutaneous pinning
Indications
- tongue type fractures
- joint depression fractures not suitable for ORIF
- compound fractures
A. Technique 1 for IA Fractures
Position
- patient prone with knee flexed
1st steinmann pin (if comminuted IA)
- from medial to lateral through body
- traction to restore height
- correct varus
- manually compress heel to reduce lateral wall displacement
2nd steinmann pin
- Posteromedial corner of posterior tuberosity
- aim towards sole and towards CCJ
- under thalamic portion, then lever pin dorsally
- aiming to correct Bohler's
- then aim towards CCJ and can even pass through
Incorporate 2 pins into plaster
- remove after 6 weeks
B. Technique 2 Stulik et al JBJS Br 2006 for IA Fractures
Transverse Steinmann as above
- disimpact fragments
- pull out of varus
Plantar stab incision
- posterior facet elevated with bone punch
Longitudinal Steinmann pins x 2
- elevate and hold thalamic portion
Transverse K wires under posterior facet
Results
- 1.7% deep infection
- 7% superficial infection
C. Technique 3 for IA fractures
Percutaneous screws + Ilizarov
D. Technique 4 Stulik et al for tongue type
Reduce tongue with longitudinal Steinmann
Fix with 2 mm K wire / screws
3. STJ Arthrodesis
Indications
- type IV Sanders
- late STJ OA
Early
- ORIF with lateral plate
- 2 x 6.5 mm screws
Late
- In setting on previous fracture very difficult
- Still have to restore anatomy
- restore heel height & width
- may have skin problems if have very planovalgus foot
- may need lateral bone block
- need lateral wall ostectomy
