Point-Counterpoint: Is It Time To Retire Internal Fixation For Calcaneal Fractures?

Yes.

These authors note that external fixation provides better results for intra-articular calcaneal fractures, citing advantages including rigid stabilization, a shorter time to reduction and greater patient mobility.   

By John F. Grady, DPM, FASPS, FACFAOM, FAAPSM, FACWM, and Jake Ruff, DPM

First, let’s be specific. It is time to retire internal fixation for intra-articular calcaneal fractures as there remains a place for internal fixation in less severe calcaneal fractures.

Berkeley and colleagues published a paper that called into question the approach to calcaneal fracture management when they found similar results between surgical treatment and conservative treatment in this patient population.¹ However, more recent research has found that patients who had surgical management are six times less likely to need a subtalar joint arthrodesis.²

Open reduction internal fixation (ORIF) of intra-articular fractures has been the popular choice of surgical correction for decades despite the extensive amount of research showing the number of complications that can be associated with a lateral extensile approach.^3-20 There is significant research showing that a percutaneous approach using external fixation can outperform traditional ORIF for intra-articular fractures.
 
Key Reasons To Retire Internal Fixation for Intra-Articular Calcaneal Fractures

Why should we retire internal fixation for intra-articular fractures of the calcaneus? There are numerous reasons such as the associated soft tissue complications and needing to wait to get swelling under control (delaying time to surgery and thus delaying return to work), to name a few.

Delayed time to operation. In order to perform ORIF, it is highly recommended that one delay surgical intervention until swelling has subsided and normal skin lines have returned. This can delay surgical intervention, which has been associated with poorer outcomes.^3,4 Abidi and colleagues found a significant increase in wound infections when surgeons delayed intervention longer than five days.⁴ The longer the delay of surgery, the more difficult the reduction becomes for ORIF.⁵

Soft tissue complications. One of the most common complications associated with ORIF of calcaneal fractures is wound complications associated with the lateral extensile incision, which remains the gold standard.⁶

The incidence of wound complications associated with the popular lateral extensile approach ranges from 7 to 37 percent.^7,8 Koski and coworkers found wound healing to be problematic in 24 percent of their 148 operatively treated calcaneal fractures with 16 percent being infection-related and 8 percent with wound edge necrosis.³ When treating displaced intra-articular calcaneal fractures, Kavin and coworkers noted that 33 percent of their patients experience necrosis at the skin margins of their lateral extensile incision.⁹ Ding and colleagues had a 17.8 percent postoperative wound complication rate in the study’s 490 operations for calcaneal fractures with ORIF.¹⁰ However, smaller incisions, like those surgeons employ with the sinus tarsi approach, have led to wound complication rates ranging only from 0 to 15 percent.¹¹

Wound complications with the traditional ORIF approach have also been associated with a number of factors.¹⁰ These include the Sanders classification of the fracture, the number of residents and surgeons operating in the case, the number of people in the operating room at the time of surgery, tobacco use and diabetes.

Other soft tissue complications such as iatrogenic acute neurological injuries, are common with calcaneal fractures. The plantar branches of the tibial nerve, the tibial nerve itself and the sural nerve are the most commonly affected. The sural nerve is reportedly damaged 6 to 15 percent of the time with the traditional lateral incision whereas the calcaneal branch of the tibial nerve is affected 25 percent of the time with a medial incision.^12,13 Haugsdal and colleagues reported that up to 23 percent of patients had nerve pain following a lateral extensile approach.¹⁴

The current literature supports percutaneous approaches, regardless of technique, as there is a significant decrease in complication rates in comparison to open approaches.¹⁵

Post-traumatic subtalar joint arthritis. Subtalar joint arthritis is a common complication of calcaneal fractures even when there is surgical treatment.¹⁶ Subtalar joint arthritis can often require reoperation. Folk and coworkers found a reoperation rate of 21 percent in 190 calcaneal fractures treated with traditional ORIF.¹⁷ Tantavisut and coworkers found a normal range of motion of the subtalar joint in only 24 percent of their patients following ORIF.¹⁸ McGarvey and colleagues had no secondary subtalar joint fusions in their study of 31 intra-articular calcaneal fractures treated with a small-wire circular frame.¹⁹

Return to work. Patients with an intra-articular calcaneal fracture return to work faster with a percutaneous approach in comparison to the traditional ORIF. Takasaka and colleagues found that despite all of their patients returning to work, regardless of the surgical approach, 50 percent of the traditional ORIF group resumed work at a different capacity.²⁰  

In a comparison of three different surgical approaches for the treatment of intra-articular calcaneal fractures, Takasaka and colleagues found that those who had percutaneous fixation had 65 percent good to excellent results using the American Orthopedic Foot and Ankle Society (AOFAS) score.²⁰ These results far outperformed the traditional lateral extensile open approach in the study.

A Closer Look At The Benefits Of External Fixation

External fixation of intra-articular calcaneal fractures provides rigid stabilization, minimal invasion, shorter time to reduction, the same extra-articular reductions as traditional ORIF, restores heel height and width, and allows for patient mobility as well as the ability to diastase a damaged joint.^17,21

External fixation also provides an option for patients who otherwise may not be ideal surgical candidates due to issues such as peripheral vascular disease, uncontrolled diabetes and smoking to name a few.^22,23 Furthermore, external fixation allows for the distraction of the subtalar joint, which, while not proven, may be protective of the cartilaginous surfaces and the periarticular soft tissue as well as aid in the maintenance of reduction of the posterior facet.24

Case Study: Addressing A Calcaneal Fracture With External Fixation In A 52-Year-Old Car Accident Victim

A 52-year-old motor vehicle accident victim got a referral from the emergency room to our office 55 hours after sustaining a calcaneal fracture.

The physical exam demonstrated an intact neurovascular status. Edema was massive and skin was totally intact. After discussions about treatment options, the patient chose surgical reduction with external fixation. Initially, we used four-layer compression and elevation reduced edema for three days. After reducing edema, we performed ORIF. It was necessary to use two small incisions to insert a bone hook posteriorly both medially and laterally to get adequate reduction prior to application of the external fixator. We then were able to distract the posterior fragment with the fixator. Using olive wires, we stabilized the medial fragment in a lateral direction at the same time as applying tension to the lateral fragment medially.

Postoperatively, the patient continued in the external fixator non-weightbearing for eight weeks followed by partial weightbearing (bearing one-third of his weight during the ninth and 10th weeks, followed by two-thirds weightbearing for the 11th and 12th week) in the external fixator.

We removed the fixator after the 12th week. The patient had physical therapy for four weeks, wore supportive running shoes for the next two months and ambulated with a cane for the 13th and 14th week. After that, the patient was able to walk normally in normal footgear. He has been pain-free without symptoms as an active carpenter for the past five years. During the entire episode postoperatively, the patient gained 12 pounds, which he has since lost in addition to two more pounds.

In Conclusion

There seems to be ample evidence showing that using ORIF for intra-articular calcaneal fractures does not provide ideal results. While the published research on external fixation for the treatment of intra-articular calcaneal fractures is not abundant, it is our opinion that the external fixation provides superior results in comparison to ORIF.

Dr. Grady is the Director of Podiatric Residencies at Advocate Christ Medical Center and Advocate Children’s Hospital in Illinois. He is an Adjunct Professor of Biomechanics and Surgery at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University. Dr. Grady is the Director of the Foot and Ankle Institute of Illinois, and the Director of the Foot and Ankle Institute for Research (FAIR).

Dr. Ruff is a third-year resident at Jesse Brown Veterans Affairs Medical Center in Chicago.

References

1. Buckley R, Tough S, McCormack R, et al. Operative compared with non-operative treatment of displaced intra-articular calcaneal fractures. J Bone Joint Surg. 2002; 84-A(1):1733–1743.
2. Agren PH, Wretenberg P, Sayed-Noor AS. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2013; 95(15):1351–1357.
3. Koski, H. Kuokkanen, E. Tukiainen. Postoperative wound complications after internal fixation of closed calcaneal fractures: a retrospective analysis of 126 consecutive patients with 148 fractures. Scand J Surg. 2005; 94(3):243–245.
4. Abidi NA, Dhawan S, Gruen GS, Vogt MT, Conti SF. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Foot Ankle Int. 1998;19(12):856-861.
5. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg. 2000; 82(2):225–250.
6. Stapleton JJ, Zgonis T. Surgical treatment of intra-articular calcaneal fractures. Clin Podiatr Med Surg. 2014; 31(4):539–546.
7. Koutserimpas C, Magarakis G, Kastanis G, Kontakis G, Alpantaki K. Complications of Intra-articular Calcaneal Fractures in Adults. Foot Ankle Specialist. 2016; 9(6):534–542.
8. Hsu AR, Anderson RB, Cohen BE. Advances in surgical management of intra-articular calcaneus fractures. J Am Acad Orthop Surg. 2015; 23(7):399–407
9. Kavin K, Vijay S, Devendra L, Kamran F. Patient satisfaction after open reduction and internal fixation through lateral extensile approach in displaced intraarticular calcaneal fractures (Sander’s type II and III). J Orthoped Trauma. 2016; 7(4):1–6.
10. Ding L, He Z, Xiao H, Chai L, Xue F. Risk factors for postoperative wound complications of calcaneal fractures following plate fixation. Foot Ankle Int. 2013; 34(9):1238–1244.
11. Schepers T. The sinus tarsi approach in displaced intra-articular calcaneal fractures: a systematic review. Int Orthop. 2011; 35(5):697-703.
12. Kitaoka HB, Schaap EJ, Chao EY, An KN. Displaced intra-articular fractures of the calcaneus treated non-operatively. Clinical results and analysis of motion and ground-reaction and temporal forces. J Bone Joint Surg Am. 1994; 76(10):1531-1540.
13. Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M, et al. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. Br Med J. 2014; 349:g4483.
14. Haugsdal J, Dawson J, Phisitkul P. Nerve injury and pain after operative repair of calcaneal fractures: a literature review. Iowa Orthop J. 2013;33:202-207.
15. Wallin KJ, Cozzetto D, Russell L, et al. Evidence-based rationale for percutaneous fixation technique of displaced intra-articular calcaneal fractures: a systematic review of clinical outcomes. J Foot Ankle Surg. 2014; 53(6):740–3.
16. Guerado E, Bertrand ML, Cano JR. Management of calcaneal fractures: what have we learnt over the years? Injury. 2012; 43(10):1640-1650.
17. Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures: Analysis of 190 fractures. J Orthop Trauma. 1999; 13(5):369–372.
18. Tantavisut S, Phisitkul P, Westerlind BO, Gao Y, Karam MD, Marsh JL. Percutaneous reduction and screw fixation of displaced intra-articular fractures of the calcaneus. Foot Ankle Int. 2017; 38(4):367–74.
19. McGarvey WC, Burris MW, Clanton TO, Melissinos EG. Calcaneal fractures: indirect reduction and external fixation. Foot Ankle Int. 2006; 27(7):494–9.
20. Takasaka M, Bittar CK, Mennucci FS, de Mattos CA, Zabeu JLA. Comparative study on three surgical techniques for intra-articular calcaneal fractures: open reduction with internal fixation using a plate, external fixation and minimally invasive surgery. Revista Brasileira De Ortopedia. 2016; 51(3):254–260.
21. DeWall M, Henderson CE, McKinley TO, Phelps T, Dolan L, Marsh JL. Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures. J Orthop Trauma. 2010;24(8):466–72.
22. Besch L, Radke B, Mueller M, Daniels-Wredenhagen M, Varoga D, Hilgert RE, et al. Dynamic and functional gait analysis of severely displaced intra-articular calcaneus fractures treated with a hinged external fixator or internal stabilization. J Foot Ankle Surg. 2008; 47(1):19–25.
23. Emara KM, Allam MF. Management of calcaneal fracture using the Ilizarov technique. Clin Orthop Rel Res. 2005; 439:215–220.
24. Dayton P, Feilmeier M, Hensley NL. Technique for minimally invasive reduction of calcaneal fractures using small bilateral external fixation. J Foot Ankle Surg. 2014; 53(3):376–82.

No.

Surveying the literature and offering insights from his experience, this author finds that open reduction and internal fixation with the lateral extensile approach can achieve sufficient anatomic reduction of calcaneal fractures.

By Benjamin D. Overley, Jr., DPM, FACFAS

Calcaneal fractures are among the most difficult fractures that we deal with as they are challenging to reduce and carry a high morbidity rate. Wound infection is the most common complication with a 13 percent incidence after fracture treatment.¹ The literature likely attributes this to the high-energy nature of the trauma and limited vascularity in the narrow soft tissue envelope overlying the lateral calcaneus.
Calcaneal fractures are also concerning for post-traumatic arthritis of the subtalar joint, which reportedly requires subsequent arthrodesis at an incidence of 7 percent within a mean follow-up of 4.6 years.¹ Certainly with increased fracture comminution, displacement and depression of the subtalar joint, one would expect poorer overall outcomes.

In a level I study, Buckley and colleagues demonstrated that there was very little difference in functional outcomes of patients who had surgical reduction in comparison to those who had non-operative treatment.² Factors that did seem to influence outcomes in calcaneal fractures included age, gender, bilaterality, workload, reestablishment of Böhler’s angle, fracture type and the quality of the reduction. Buckley concluded that anatomic or near anatomic (less than 2 mm step off) reductions enhance outcomes.

What You Should Know About The Lateral Extensile Approach

If the quality of the reduction can play even a small role in a more favorable outcome, then surgeons should endeavor to reestablish the calcaneus as anatomically as possible. The best way to achieve a perfect or near perfect anatomic reduction of calcaneal fractures is open reduction and internal fixation (ORIF) utilizing the lateral extensile approach.

Fractures of the calcaneus come in many patterns. Research has shown that non-displaced and extra-articular fractures do well with non-operative or minimally invasive, percutaneous fixation.² On the other hand, the literature has demonstrated that displaced intra-articular fractures require open reduction and internal fixation for better outcomes.³ In another level I study, Huang and colleagues recommend treating Sanders Type II, Type III, and Type IV calcaneal fractures with ORIF and use of the standard lateral extensile approach.³

In the recent literature, we have seen the emergence of minimally invasive fixation for displaced intra-articular calcaneal fractures with the prevailing argument being that it decreases soft tissue complications. What this argument leaves out is the incidence of malreduction and the need for concomitant large bone block introduction to restore some semblance of normal anatomy.

Basile and coworkers compared the lateral extensile approach and the sinus tarsi approach for the treatment of Sanders II and III fractures.⁴ For the lateral extensile approach group, they reported a 7.9 percent complication rate with all complications being wound-related with only one patient requiring a secondary surgery. The study authors noted a 5.3 percent complication rate with the sinus tarsi approach. One of the complications was a varus malreduction and another was peroneal irritation requiring hardware removal and debridement. Evaluation and analysis of the long-term outcomes of these patients are ongoing, according to the study.

The most important principles of calcaneal fracture reduction are restoring the posterior facet height of the subtalar joint and reducing the posterior tuber, both out to anatomic length and out of frontal plane varus. Although there are many methods to attempt both of these percutaneously and while this fixation can provide structural support for the fracture, I have found it often fails to achieve the near anatomic reduction required to improve overall outcomes. The lateral extensile approach gives surgeons a clear advantage in visualizing the posterior facet reduction and the fixation supporting it. The lateral extensile approach also allows for instrumentation to lift the facet back into position and the application of a bone graft to fill any void that may be present.

Some have argued that the lateral extensile approach leads to notoriously difficult incision healing. I have found that if the surgeon uses a good “no touch” technique with a full-thickness flap protecting the peroneal tendons, the sural nerve and the vasculature, complications are significantly lower. I also utilize the Allgower-Donati suture technique often to protect the integrity of the soft tissue flap.
I must also note that these wound complications usually arise in those treated by young or inexperienced foot and ankle surgeons. Often, surgeons take these patients to the operating theater too soon (less than five days) before the lateral soft tissue has had time to reduce in swelling or declare any development of fracture blisters. Of primary concern is the development of hemorrhagic blisters, which should serve as a sentinel warning (poor tissue extending to the osseous architecture) to either proceed at a later date, apply a soft tissue vacuum to expedite this process or consider a percutaneous approach.

A Closer Look At The Author’s Surgical Technique

My preferred surgical technique utilizes the lateral extensile approach to allow access for application of a locking plate with polyaxial screws to purchase the sustentaculum and support the posterior facet. I prefer to use only minimal screw fixation in the plate when possible (most fractures are stable and secure with five to seven total screws) with two screws supporting the posterior facet and two screws reducing the posterior tuber. I limit the number of screws placed and I am conscious of where I place them so as to allow for subsequent subtalar arthrodesis without needing to remove all the hardware of the lateral calcaneus. Additionally, I feel that retaining the hardware allows the plate to provide structural support when one is using a compression screw for the subsequent subtalar arthrodesis.

It is very common that the post-traumatic arthritis secondary to a calcaneal fracture is severe enough to require a secondary subtalar joint arthrodesis. Research has shown that patients treated non-operatively are 5.5 times more likely to require a subtalar arthrodesis than those who had surgical reduction.² For Sanders IV fractures, a lateral extensile approach is advantageous because if the subtalar joint is so comminuted that one cannot reconstruct it, the surgeon can perform a primary subtalar arthrodesis.³ Radnay and colleagues found that patients who initially had ORIF of their calcaneal fractures to restore and preserve the architecture of the hindfoot had much better clinical outcomes after having subtalar arthrodesis many years later.⁵

In Conclusion

Currently, there is a lack of level I evidence directly comparing percutaneous fixation to the lateral extensile approach. Percutaneous fixation has limited application dependent upon the fracture pattern and surgeon skill set. While percutaneous fixation has its place, it may not be appropriate for all fractures or all patients. In the case of more severe comminution or significant joint depression such as a Sanders IV fracture, surgeons should use a lateral extensile approach to restore the normal anatomy as much as possible.

Dr. Overley is affiliated with Coventry Foot and Ankle Surgery in Limerick, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons.

The author thanks Lindsy Kragt, DPM, a second-year resident at Phoenixville Podiatric Surgical Residency Program in Phoenixville, Pa., who assisted with all components of this article.

References

1. Veltman ES, Doornberg JN, Stufkens SA, Luitse JS, van den Bekerom MP. Long-term outcomes of 1,730 calcaneal fractures: systematic review of the literature. J Foot Ankle Surg. 2013;52(4):486-490.
2. Buckley R, Tough S, McCormack R, et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84-A(10):1733-1744.
3. Huang PJ, Huang HT, Chen TB, et al. Open reduction and internal fixation of displaced intra-articular fractures of the calcaneus. J Trauma. 2002;52(5):946–50.
4. Basile A, Albo F, Via AG. Comparison between sinus tarsi approach and extensile lateral approach for treatment of closed displaced intra-articular calcaneal fractures: a multicenter prospective study. J Foot Ankle Surg. 2016;55(3):513-521.
5. Radnay CS, Clare MP, Sanders RW. Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter? J Bone Jt Surg Am. 2009;91(Part 1):541-546.

Editor’s note: For a related article, see “Point-Counterpoint: Should You Perform Minimal Incision Or Extensile Lateral Incision For Calcaneal Fractures?” in the July 2014 issue of Podiatry Today, or visit the archives at www.podiatrytoday.com .