Open reduction and internal fixation for displaced intra-articular fractures of the os calcis

Injury Vol. 26, No. 2, pp. 111-115, 1995 Copyright 0 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved OOZO-1383/95 $lO.OO+O.OO

UTTERWORTH EINEMANN

Open reduction and internal fixation for displaced intra-articular fractures of the OS calcis S. Chanl

and F. K. Ip’

‘Department of Orthopaedic Surgery, University Youde Nethersole Eastern Hospital, Hong Kong

of Hong Kong, Queen Mary Hospital, Hong Kong, and 2Pamela

Thirty-one patients wifh displaced infra-arficular fracfwre of the OS calcis who were admitted to Queen May Hospital, Hong Kong from 1989 fo 1991 and who underwent open reduction and infernalfixation and bone grafting of the OS calcis, were followed up for af leasf 30 months. Pre- and posfoperafive X-rays were taken. Functional results were assessed clinically in ferms of pain, deformities, acfivifies and rnofion loss. The majority of the patients had acceptable functional otctcome. The results were analysed in an attempt to correlate with the fracture

pattern.

Injury, Vol.

26,

111-115,

1995

Introduction Fracture of the OScalcisis a seriousinjury and often leadsto prolonged suffering including pain, deformities and unemployment’-3. This is particularly so in intra-articular fracture“. In a recent reviews, many different treatment methods were quoted. Various results are difficult to compare because,first, different methods of classifications are employed, second,few studiesinclude accurate assessment of the fracture by CT scanning, and thirdly, no standardized method is used to assessclinical results. The long-term results of non-operative treatment by Nade and Monachar+ and Pozo4, and unsatisfactory results in highdemand manual workers in our experience’ has led us to perform a study of open reduction, internal fixation and bone grafting for displacedintra-articular fracture of the OS calcis.

Methods Between January 1989 and June 1991, we had 40 patients with displaced intra-articular fractures of the OScalcis.We used Essex-Lopresti’s classification of intra-articular fracture (TableI); these were all type IIB fractures with displacement (TableII) probably because of a predominance of construction site injuries in our series.The criteria of significant displacement were either the Bijhler’s angle of 10” or lesswith reference to the contralateral side (range of 25 to JO”), or the greatest depressionof calcanealheight of 10 per cent or more, measuredfrom the highest point of the posterior facet of the subtalar joint on the lateral radiograph, or an increaseof the greatest calcanealwidth

of IO per cent or more shown on the axial view of the OS calcis (Figztres z and 2). These criteria have been shown to reflect the severity of the injurys,g. These patients underwent open reduction, internal fixation and bone grafting from the lateral approach described by PalmerlO.The aim was stable anatomical reduction of the articular surface, achieved by elevation and fixation of the posterior facet (medial or lateral) of the subtalar joint, by buttress plating of the lateral cortex and corticocancellous bone grafting of the defect in the OScalcis. Nine patients were lost to follow-up, 3 I were available for study. The follow-up period was from 30 months to 58 months, with an average of 44.3 months. The patients’ age profile is shown in Figure 3. There were 29 malesand two females. Fourteen patients injured their left foot, 13 their right, and four both. Twenty-nine patients were injured as the result of a fall from height. Four patients had associated injuries, of which two had ipsilateral trochanteric fractures Table I. Essex-Lopresti’s classificationof OScalcisfractures I. Fractures not involving the subtalar joint A. Tuberosity fractures I. Beak type 2. Avulsion of the medial border 3. Vertical fracture 4. Horizontal fracture B. Fractures involving only the calcaneocuboid joint 1. Parrot-nose type 2. Various types II. Fractures involving the subtalar joint A. Without displacement B. With displacement 1. Tongue-type of displacement 2. Central lateral depression of the joint 3. Sustentaculum tali fracture 4. Comminution from below (including severe tongue and joint depression types) 5. From behind and forward with dislocation of the subtalar joint

Table II. Distribution of fracturetypes in the group studied (all

Essex-LoprestiIIB with displacement) Tongue type Joint depression Cornminuted type Calcaneocuboid joint

involved

IO 14 11 7

Injury:

International

Journal

of the Care of the Injured

Vol. 26, No. 2, 1995

Figure 1. Lateralview radiographshowingthe lossof B&l&s

Figure 2. Axial view radiographshowingthe increasein cal-

angleanddepressed posteriorfacet of subtalarjoint.

canealwidth.

of the hip and two had head injuries. All patients were operated on within the first 96 h, as soon asa CT scanwas available. Postoperatively, patient practised non-weightbearing walking when the drain was out; active ankle and subtalarjoint movement was encouraged. Gradual weight bearing walking started at 6 to 8 weeks, then full weight bearing.

taking advantage of the multi-slicing property of CT scanning.The percentage of lateral or medial facet depression and increasein the greatest calcanealwidth between the similar cut were expressed as a perecentage, thus eliminating any magnification factor. In Figure6, the percentage of medial facet depressionwould be h’/h %, and the percentage increase in the greatest calcaneal width would be WI/W%. The results shown in TableIV.

Assessment

Pre-operative assessmentincluded any concomitant injuries. Post-operative wound healing was monitored. Reassessmentwas by questionnaire. Pain was graded as none, mild and inconstant, or moderate and constant; deformities were widened heel affecting footwear, flat feet, hindfoot varus or valgus; ankle and subtalar motion were measured with a goniometer and compared with the normal side; walking ability, employment and sports were recorded. Radiologically, preoperative radiographs included AP of the foot, lateral of the ankle/foot and axial view of both OScalcis.The pre-operative radiography of the normal and injured foot (bilateral are excluded), the loss of Bohler’s angle, the posterior facet depression and the increase in greatest calcaneal width were measured(Figures I, 2 and TableIII). Post-operative lateral and axial radiographs were taken to compare with the injury films to measure the improvement of Bohler’s angle and posterior facet height ,(Figtlres4, 5 and TubleIII). On follow-up X-rays, any late collapseor osteoarthritis were noted. CT scansof the hindfoot were taken in the coronal plane (Figure 6), the cut with the most severe facet depression was compared with a similar cut of the contralateral foot,

Results Radiological pre- and postoperative measurements are shown in TablesIII and IV. Upon follow-up there was no Number “I

____

41-50

51-80

61-70

Age

Figure. 3 Age distribution of the group studied(range20-73 years).

Chan and Ip: Displaced

fractures

of the OS calcis

113

Table III. Pre-andpost-operativeradiologicalmeasurements of Bohler’sangle,posteriorfacet height and calcanealwidth Post-op

Pre-op Loss of Bohler’s angle - 34.6 (-21 - -47”) Post. facet depression - 7.1 mm (-2mm-11 mm) Increase calcaneal width +14.1 mm (+9mm+18mm)

Bohler’s

angle

improvement

+26.7"(+8-+53') Post. facet elevation (+l mm+27mm) Reduced calcaneal -7.5mm (Omm-

+ 26 mm width --17mm)

Table IV. CT scanfindingsof the group studied Pre-op

Post operative lateral view radiographshowingthe restorationof Bbhler’sangleand calcanealheight. Figured.

Lateral

facet

depression

-26.5%(0-45%) Medial

facet

depression

-15%(0-33%) Lateral

bulge

increase

39.4%(0-66%)

non-union; osteoarthritic changes of the subtalar joint were mild in seven feet and moderate to severe in two. Clinical results are charted in terms of pain, deformities, activities and motion loss (Figures T-10). About two-third of the patients are pain free; most patients have mild and inconstant swelling, which did not affect footwear. Only one-third of patients returned to manualwork and none of our patients returned to sport. There was greater motion lossat the subtalar joint than at the ankle joint. Infection occurred in three; two had deep infections resulting in chronic osteomyelitis; one patient was a 73-year-old diabetic with atherosclerosiswho subsequently required a below-knee amputation; we think that the decision for open reduction was incorrect. Sural nerve damage occurred in three; reflex sympathetic dystrophy occurred in three; they had generalized pain and patchy osteoporosis radiologically. All were treated nonoperatively with nerve block and medications.

Discussion In the group studied, there was a high incidence of young male construction-site workers with a comminuted fracture. The subtalarjoint disruption, asreflected in the lossof Bohler’s angle, has been frequently described’1-14. Flatfoot, varus/valgus heel and widened heel resulted in weakened plantar flexion and difficulties in normal shoewear. These deformities persisted and resulted in substantial disabilityr’. Open reduction and internal fixation of the intraarticular fracture of the OScalcishasbeen advocated’0,‘6-rs and the results have been encouragingr9. We followed Maxfield’s recommendationzOto treat all displaced intraarticular fractures of the OScalcis by open reduction and internal fixation. In all our patients Palmer’s lateral approach was adequate.We agreed with Hazlettz’ that the posterior facet is frequently divided longitudinally and is best fixed with a transverse screw. We found that lateral plating gave a good buttressing effect upon the lateral wall, which frequently bursts out in OScalcis fractures. We also found measurementof the screw length gave a good idea of the reduction of the calcaneal width; the normal

Figure 5. Postoperativeaxial view to showthe reductionof the

calcanealwidth.

Figure 6. The coronalcut CT scanshowingthe incongruity of

the subtalarjoint.

Injury:

114

International

No of feel 25

20

15

10

I

6

0

p&h

r&i

con.

TENDERNESS

Journal

of the Care of the Injured

Vol. 26, No. 2, 1995

seems constant at 38 f 2 mm. This is crucial, as the spreadingof the OScalcisunder the fibula is associatedwith a poor long-term prognosiszz. With all these techniquesour results showed that union was prompt; full weight bearing can usually be achieved within 3 months without significant late collapse, which may be attributed to using corticocancellous bone graft. Our results showed that the deformity was infrequent and footwear was not a problem, yet one-third of the patients still have pain, and the ability to return to manualwork was low. We think that the pathologies of persistent pain are multi-focal. Upon a multi-variance study, it was correlated to two recorded parameters; the loss of subtalar motion

s/T435

Figure 7. Results in terms of pain at 30 months. N= 31. No of feet 25r

Figure 8, Results in terms of deformities

at 30 months. N= 31.

Figure 11. Plantarflexion

of the operated foot.

0 of aatients 35 30 25 ,2c I15 i1c If i-

IL

c

WALKING

JOBS

“““““”

SPORTS

Figure 9. Results in terms of activities at 30 months. N= , 31. I

601

/ degrees

28

12.2

0’

Ill ANKLE DORSIFLEXION

10.4

4 ANKLE PLANTARFLEXION

1L

SUETALAR INVERSION

Figure 10. Results in terms of motion range, cross bars show means.

SUE IT ALAR EVE iR SION

loss. Columns

-

show Figure 12. Dorsiflexion

of the operated foot

Chan and Ip: Displaced

fractures

of the OS calcis

and the continued type fracture (paired f-test, Pc0.05); this lack of correlation with all other factors considered suggests that pain was primarily related to the energy of trauma. Our results showed a marked loss of subtalar movement which is similar to other series*‘. We do not use postoperative immobilizationZ1 and patients walk with a brace that allows free ankle and foot movement. Reviewing our complications, we would now advocate operative treatment only for patients between the ages of 15 and 6523.

Conclusion Open reduction, internal fixation and bone grafting for displaced intra-articular fracture of the OS calcis produces an acceptable cosmetic and functional foot (Figtlres II and 12). At least one-third of the patients have residual pain and return to a high-demand job is low. The incidence of early osteoarthritis is low; the long-term benefit of an operative approach is as yet unproven.

References

10 Palmer I. The mechanism and treatment of fracture of the calcaneus. Open reduction with the use of cancellous graft. J Bone Joint Surg [Am] 1948; 30Az 2. II Sarrafian SK. Anafomy of the Foot and Ankle: Descriptive, Topographic and Function. Philadelphia: J.B. Lippincott, 1983. 12 Gilmer PW, Hersenberg J, Frank L. Computer tomographic analysis of acute calcaneal fracture. Foot Ankle 1986; 6: 184. 13 Guyer B, Levinshohn M, Fredrickson BE. Computer tomography of the calcaneal fractures, anatomy, pathology dosimetry and clinical relevance. AmJRadioll985; 145: 911. 14 Lowrie IG, Finlay DB, Brankel IJ. Computerized tomographic assessment of the subtalar joint in calcaneal fractures. j Bone Joinf Surg [Br] 1988; 70B: 247. 15 Pridie KH. A new method of treatment of treatment for severe fractures of the OS calcis. A preliminary report. Sttrg Gynaecol Obstet 1946; 82: 671. 16 Leonard MH. Treatment of fractures of the OS calcis. Arch Surg 1957; 75: 990. 17 McReynolds IS. Trauma to the OS calcis and heel cord. In: Jahss MH. ed. Disorder of the Fool, Vol. 2, pp. 1497-1542. Philadelphia: W.B. Saunders, 1982. 18 Stephenson JR. Treatment of displaced intra-articular fractures of the calcaneus using medial and lateral approaches, internal fixation, and early motion. ] Bone joint Surg [Am]

69A:115.

1 Bankart SB. Fracture of the OS calcis. Lancet 1942;ii: 175. 2 Magnuson PB. Frucfure. 4th edn. Philadelphia: J.B. Lippincott, p. 332. 3 Mercer W. Orthopaedic Surgery. London: Edward Arnold, p. 814. 4 Pozo JL. The long term results of conservative management of severely displaced fractures of the calcaneus. J Bone Joint Surg [Br] 66B: 386. 5 Giachino AA. Current concept review. Intra-articular fractures of the calcaneum. J Bone joint Surg 1989; 71A: 784. 6 Nade S, Monahan PRW. Fracture of the calcaneum, a study of the long term prognosis. Injury 4: 201. 7 Ip FK. Functional cast treatment of displaced intra-articular fracture. 1988;Personal communication. 8 Essex-Lopresti P. The mechanism, reduction technique and results in fractures of the OS calcis. Br J Surg 1952; 39: 395. 9 Salama R, Benamara A, Weissman SL. Functional treatment of intra-articular fractures of the calcaneus. Clin Orfhop 115:

236.

115

19 Hammesfahr R, Fleming LL. Calcaneal fractures: a good prognosis. Foot Ankle 1981;2: 161. 20 Maxfield JE. OS calcis fracture: treatment by open reduction. Clin Orthop 1963; 30: 91. 21 Hazlett JW. Open reduction of fracture of the calcaneum. Can ] Surg 1969; 12: 310. 22 Deyerle WM. Long term follow up of fractures of the OS calcis. Diagnostic peroneal synoviagram. Orthop Clin Norfh Am 1973; 4: 213. 23 Miller WS. The heel pad. Am ] Sports Med 1982;10: 19.

Paper accepted

22 September

1994.

Requests for reprints should be addressed to: Dr Samson Chan, Department of Orthopaedic Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong.

XII INTERNATIONAL CONGRESS OF EMERGENCY SURGERY AND INTENSIVE CARE/FIRST CONGRESS OF THE EUROPEAN ASSOCIATION OF EMERGENCY SURGERY (EAES) 17 - 20 September 1995 Oslo, Nonvny For further information pleasecontact: Professor Kaare Solheim, Congress Chairman, Surgical Department, Ullevaal University Hospital, N-0407 Oslo, Norway Fax: t-4722609846