Point-Counterpoint: Is Open Repair More Effective Than Percutaneous Ex Fix For Calcaneal Fractures?

Yes.

Although the percutaneous approach has its benefits for calcaneal fractures, this author notes that ORIF with the lateral extensile approach may be more effective when there is calcaneal displacement and may lead to better functional outcomes.

By Wenjay Sung, DPM, FACFAS

Opinions on the management of complex fractures of the calcaneus continue to differ despite improvements in technology and techniques.^1,2 Prospective studies have attempted to show benefits with early minimally invasive operative intervention versus the standard open extensile approach.^3-5

Specifically, Buckley and Meek compared surgical treatment to non-operative treatment of intra-articular calcaneal fractures with 17 patients in each group.⁴ There were no significant differences between the two groups in regard to heel pain, subtalar motion and return to work, but the study authors found that surgically treated fractures had overall better functional outcomes with anatomic reduction of the subtalar joint. In a 2001 review of randomized, controlled trials at that time, Richards and Bridgman found “weak evidence” supporting open reduction internal fixation (ORIF) for displaced calcaneal fractures.⁵  

All modalities, including non-operative measures, have at times gained more attention in the literature. However, there continues to be a subset of calcaneal fractures that experience poor long-term outcomes, regardless of approach or management.

The vast majority of surgeons agree that timing of surgery is a heavily weighted factor in achieving long-term functional outcomes. Ideally, if surgical intervention is warranted, it should occur within three weeks after the initial injury.⁶ Exceptions to this window include open calcaneal fractures and compartment syndrome in the foot, which requires immediate intervention.⁷

Ideally, waiting three weeks for surgery permits excessive swelling and fracture blisters to resolve. Additionally, this window is still sufficiently early enough to prevent the premature coalescence of fracture fragments. In the absence of blisters, skin wrinkling is an indication that excessive swelling has resolved and operative intervention may proceed.

Soft tissue is another important factor in determining surgical success as measured by the number of surgical site complications. Appropriate timing of the intervention and proper soft tissue handling require sufficient knowledge, experience and training in order to increase the likelihood of surgical success.

A Closer Look At The Literature On Surgical Repair Of Calcaneal Fractures

Researchers have described multiple surgical approaches for treatment of calcaneus fractures, ranging from minimally invasive percutaneous fixation to extensive open techniques.⁸ One may perform open extensile techniques by using medial, lateral or combined incisional approaches that depend on the extent of injury and the location of the fracture fragments.^9-11 Benirschke and Sangeorzan used an extensile lateral approach, rigid internal fixation and early post-op motion to treat more than 100 calcaneal fractures successfully, citing low morbidity and improved outcomes.⁹ Additionally, Burdeaux related good results in treating 61 displaced calcaneal fractures with ORIF via a modified medial approach technique.¹⁰ Grala and coworkers noted that a large bone distractor can be helpful in open reconstruction of articular calcaneal fractures.¹¹

The complex anatomy of the calcaneus, the presence of soft cancellous bone and the high incidence of postoperative dehiscence and infection contribute to the difficulty of open extensile intervention. However, most reports suggest that postoperative functional outcome is related to the accuracy of the subtalar joint reduction, restoring normal heel anatomy, lateral wall decompression and the ability to sufficiently control postoperative swelling.^9-11

Comparing Percutaneous Repair With Open Approaches

Calcaneal fracture reduction with percutaneous fixation has a lower risk of wound complications, a shorter operating time and more rapid healing because surgeons handle the soft tissue less.^12-14 In a study of 59 patients with 71 fractures that had percutaneous skeletal triangular distraction and percutaneous fixation, Schepers and colleagues found 72 percent had good to excellent results as measured by the American Orthopaedic Foot and Ankle Society Hindfoot Score.¹² Walde and colleagues, in a study of 67 calcaneal fractures, found that a minimally invasive technique is a viable alternative for intra-articular, dislocated calcaneal fractures.¹³ Finally, DeWall and coworkers studied 120 patients with 125 intra-articular calcaneus fractures, finding that percutaneous reduction and fixation of calcaneal fractures maintains extra-articular reductions as well as standard extensile ORIF does.¹⁴

This percutaneous surgical approach is recommended in patients with significant comorbidities, skin compromise, impaired healing or tongue-type fracture patterns. In comparison to open extensile procedures, the percutaneous fixation approach is more appealing for reducing the number of postoperative complications.

Unfortunately, the limited exposure that this technique affords may prevent adequate reduction and fixation of the calcaneal injury, thus limiting the maximum functional range and barring a return to normal functional outcome. If the anatomic joint is involved with significant step-off, ORIF via an extensile approach may be the preferred option for facilitating successful postoperative functional outcome.

Pertinent Insights On The Lateral Extensile Approach

The most described incision for exposure during ORIF of calcaneus fractures in the literature is the lateral extensile approach.⁹ This approach allows the surgeon to visualize the entire fracture and anatomic alignment. The lateral extensile incision allows complete reduction from the calcaneal tuberosity to the anterior process and exposes the calcaneocuboid joint. In addition, this approach allows indirect reduction of the medial calcaneal wall and the sustentaculum.

The lateral extensile incision should include a full-thickness skin flap. Gentle tissue handling is vital to surgical success and proper flap closure is equally important. Flap closure that avoids excessive tension on the skin and proper handling of soft tissue are critical to prevent skin necrosis as Cavadas and colleagues demonstrated in a study of 24 patients.¹⁵

In Conclusion

There is no universal agreement among experts as to the best treatment method for calcaneus fractures. However, as the literature suggests, the open extensile approach for calcaneal fracture repair may be best indicated when there is significant displacement and may permit higher functional outcomes.

Dr. Sung is a Fellow of the American College of Foot and Ankle Surgeons, and is board-certified by the American Board of Foot and Ankle Surgery. He is affiliated with St. Joseph Hospital in Orange, Calif.  

References

1. Barei DP, Bellabarba C, Sangeorzan BJ, Benirschke SK. Fractures of the calcaneus. Orthoped Clin N Am. 2002; 33(1):263-285, x.
2. Juliano P, Nguyen HV. Fractures of the calcaneus. Orthoped Clin N Am. 2001; 32(1):35-51, viii.
3. Bridgman SA, Dunn KM, McBride DJ, Richards PJ. Interventions for treating calcaneal fractures. Cochrane Database Syst Rev. 2000; CD001161.
4. Buckley RE, Meek RN. Comparison of open versus closed reduction of intraarticular calcaneal fractures: a matched cohort in workmen. J Orthoped Trauma. 1992; 6(2):216-222.
5. Richards PJ, Bridgman S. Review of the radiology in randomised controlled trials in open reduction and internal fixation (ORIF) of displaced intraarticular calcaneal fractures. Injury. 2001; 32(8):633-636.
6. Varela CD, Vaughan TK, Carr JB, Slemmons BK. Fracture blisters: clinical and pathological aspects. J Orthoped Trauma. 1993; 7(5):417-427.
7. Thornton SJ, Cheleuitte D, Ptaszek AJ, Early JS. Treatment of open intra-articular calcaneal fractures: evaluation of a treatment protocol based on wound location and size. Foot Ankle Int. 2006; 27(5):317-323.
8. Schuberth JM, Cobb MD, Talarico RH. Minimally invasive arthroscopic-assisted reduction with percutaneous fixation in the management of intra-articular calcaneal fractures: a review of 24 cases. J Foot Ankle Surg. 2009; 48(3):315-322.
9. Benirschke SK, Sangeorzan BJ. Extensive intraarticular fractures of the foot. Surgical management of calcaneal fractures. Clin Orthop Rel Res. 1993; 292:128-134.
10. Burdeaux BD, Jr. Fractures of the calcaneus: open reduction and internal fixation from the medial side a 21-year prospective study. Foot Ankle Int. 1997; 18(11):685-692.
11. Grala P, Twardosz W, Tondel W, Olewicz-Gawlik A, Hrycaj P. Large bone distractor for open reconstruction of articular fractures of the calcaneus. Int Orthoped. 2009; 33(5):1283-1288.
12. Schepers T, Vogels LM, Schipper IB, Patka P. Percutaneous reduction and fixation of intraarticular calcaneal fractures. Oper Orthop Traumatol. 2008; 20(2):168-175.
13. Walde TA, Sauer B, Degreif J, Walde HJ. Closed reduction and percutaneous Kirschner wire fixation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 2-10 years. Arch Orthoped Trauma Surg. 2008; 128: 585-591.
14. DeWall M, Henderson CE, McKinley TO, Phelps T, Dolan L, Marsh JL. Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures. J Orthoped Trauma. 2010; 24(8):466-472.
15. Cavadas PC, Landin L. Management of soft-tissue complications of the lateral approach for calcaneal fractures. Plast Reconstr Surg. 2007; 120(2):459-466; discussion 467-459.

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

No.

These authors contend that percutaneous external fixation can be effective in repairing calcaneal fractures and helps minimize complications such as infection and dehiscence.   

By Paul Dayton, DPM, MS, FACFAS, Joshua Wolfe, BS, Zachary Croy, BS, Steven Tocci, BS, Ian Richter, BA

Calcaneal fractures make up 60 percent of all tarsal fractures and 2 percent of all fractures.¹ Approximately 25 percent of calcaneal fractures are intra-articular.

Left unreduced, calcaneal fractures may lead to chronic pain from degenerative changes in the subtalar joint and the dysfunction of adjacent joints as well as structural malalignment and biomechanical stress. For this reason, most surgeons advocate for the reduction of calcaneal fractures to obtain accurate alignment and improve post-injury function. Although surgeons widely agree upon reduction, the approach to reduction of displaced intra-articular calcaneal fractures is an area of debate.

While a variety of methods have emerged to access the fracture components and achieve reduction of calcaneal fractures, many foot and ankle surgeons continue to prefer the lateral extensile incision with plate fixation.

Despite its utility to access the fractured calcaneus, the lateral extensile incision is associated with a variety of soft tissue sequelae, most notably wound dehiscence and infections that reportedly occur in up to 33 percent of cases.^2,3 Researchers have identified infection as one of the most devastating complications from surgical management of calcaneal fractures.⁴ In an attempt to reduce the post-reduction complications associated with open reduction of calcaneal fractures, many surgeons are moving toward minimally invasive reduction techniques. Recent reviews of percutaneous fixation techniques to repair intra-articular calcaneal fractures have demonstrated significant decreases in soft tissue morbidity and postoperative infections.^5-11

Furthermore, percutaneous techniques with the aid of fluoroscopy still allow the surgeon to achieve excellent alignment of the major fracture fragments of the calcaneus and the posterior facet of the subtalar joint. One carries out reduction through small incisions and the use of a variety of indirect and direct reduction techniques. Surgeons can maintain the fragments with either percutaneous placement of internal plates and screws, or the use of external fixators.¹²    

Operative Pearls For Reducing Calcaneal Fractures

Our preferred technique for reduction of calcaneal fractures involves the use of medial and lateral pins to bar external fixators to achieve alignment and spatial orientation of the fractured calcaneus in three dimensions.¹³ After bringing the main fragments of the calcaneus out to length, moving the fragments from their proximally migrated position and taking the foot out of varus, there is resulting decompression of the central calcaneus including the posterior facet fragments. This allows the ease of manipulation through a variety of direct and indirect percutaneous techniques.

We stress that it is the initial reduction of the calcaneal tuber relative to the remaining components that sets the stage to be able to reduce the remaining components. Without the decompression provided by this step, it is nearly impossible to manipulate the posterior facet fragments back into alignment. Also, the frame components need to provide for multiplanar movements to reduce the complicated structure of the calcaneus. Uniplanar “mini-rails” do not provide the freedom of movement necessary for indirect minimally invasive reduction. Skeletal traction devices can be very helpful in initiating this decompression and realignment of the calcaneal components by sustained soft tissue stretching.

Preoperative radiographic planning is essential. We recommend bilateral lateral projection and axial radiographs using the uninjured foot to give the surgeon a normal road map for proper reduction. Multiplanar computed tomography (CT) scanning can also be very helpful in understanding the fracture fragment alignment, especially the subtalar joint components.

As we noted above, it is both intra-articular reduction and conservation of the 3D spatial positioning of the calcaneus that are essential for proper biomechanical movement of the ankle, hindfoot and midfoot, which drives good functional results. A perfect posterior facet alignment in a foot with a shortened, proximally migrated or varus positioned calcaneus will not function well. Additionally, if late reconstruction due to arthritis is necessary, arthrodesis must include reconstruction of the length and angulation of the calcaneus to be effective.

Our external fixation technique takes into account the spatial orientation of the calcaneus and provides free modulation of the calcaneal length, the degree of varus, and the positioning of the calcaneal tuberosity before considering posterior facet reduction and fixation.¹³ Correction of varus ensures a lack of pronatory compensation and excess valgus stress within the midfoot resulting from an otherwise improperly placed, varus positioned calcaneus. The lengthening of the calcaneus is equally significant and one must spatially adjust this to reduce excessive anterior loading forces on the ankle and resulting weakened posterior muscle pull. Once reduction of the major fragments occurs, the posterior facet fragments are mobile and the surgeon can easily perform reduction and fixation.

A Closer Look At The Benefits Of External Fixation

Although there are many different techniques that surgeons can employ for the reduction and fixation of calcaneal fractures, a unique benefit of the percutaneous approach is the option to perform acute reduction without a prolonged preoperative delay.¹³ Quite often, edema and posttraumatic induration necessitate a waiting period prior to open treatment. Surgeons widely recommend this waiting period to reduce the “second hit” phenomenon on the calcaneal soft tissues and widely believe the waiting period reduces the incidence of complications.¹³ One can avoid this in external fixation because the minimally invasive procedures cause very little second hit on the soft tissues.

This is important as there may be a correlation between an increased number of days between the trauma and corrective surgery as one may see with open reduction internal fixation (ORIF).² A retrospective study followed the use of ORIF procedures for 63 patients.² Of those patients, researchers found those who received ORIF an average of 4.8 days after injury had fewer complications in wound healing (16.6 percent). In contrast, those who had ORIF 10 days after injury had a 42.5 percent incidence of complications in wound healing.

Another benefit of our technique of using pins to bar fixators both medial and lateral from the talus to the calcaneus is that of arthrodiastasis of the joint surfaces at the subtalar joint. The fixator maintains the initial decompression during recovery, reducing the compressive stresses on the fracture fragments as well as the compressive forces on the cartilage. Although we have no proof that this allows for better healing, it certainly may be a factor in the positive outcomes. Arthrodiastasis can be beneficial in other joints and we feel this is a major benefit of this technique.

We are well aware through scientific reports that incisions for ORIF, specifically the lateral extensile incision, in some cases compromise the local blood supply, nerve bundles, tendons and skin.¹² Accordingly, it stands to reason that the minimally invasive percutaneous external fixation techniques available offer a solution for patients who may have underlying comorbidities, including diabetes mellitus, peripheral vascular disease and tobacco use.

Emerging Insights From The Literature On Percutaneous Fixation

In addition, percutaneous external fixation with fluoroscopy provides a unique perspective on the posterior facet and provides eased restoration of Bohler’s angle before fixation due to decompression. One can also employ non-invasive methods of reduction such as ligamentotaxis when the central calcaneus has decompression.¹²

The outcomes following percutaneous fixation of calcaneal fractures are quite promising. According to a recent systematic review using American Orthopaedic Foot and Ankle Society (AOFAS) scores, the Maryland Foot Score and the Creighton-Nebraska Health Foundation Assessment Scale, there were 79 percent good and excellent outcomes for those who had percutaneous fixation versus 65 percent for those who had ORIF.¹⁴

Additionally, a typical patient who suffers from an intra-articular calcaneal fracture is a male between 21 to 40 years old.¹⁵ An outcome of importance is the ability to return to work and perform for the remainder of the patient’s earning years. Multiple studies have shown a statistically significant difference in the ability to return to work when comparing ORIF to percutaneous techniques.^15-16 According to a recent study comparing multiple reduction techniques, 100 percent of those who had percutaneous external fixation were able to return back to their previous work. All of the patients who had ORIF with plate fixation were able to return to work but 50 percent of these patients had to resort to different work activities because of their reduced abilities.¹⁵ When comparing the time taken before returning to work, patients with ORIF took an average of 6.2 months in comparison to the percutaneous fixation group, who took an average of 2.9 months.¹⁶ The ability to return to work earlier, up to twice as fast as those who receive ORIF, can make a huge impact on the financial and emotional burden of the family.

Roukis and colleagues found that in 66 patients with intra-articular calcaneal fractures, external fixation was able to restore calcaneal height, length, width and axial alignment within acceptable standards.¹⁷ Within their study, the arthrodiastasis that occurred with external fixation may have aided in decreased stiffness in the ankle and rearfoot as well as avoiding the development of osteoarthritis.¹⁷

In Conclusion

Percutaneous reduction by external fixation is a viable option for calcaneal fracture repair. While external fixation employs many different approaches, evidence supports the notion that external fixation provides a method of control for diminished wound dehiscence and decreased risk complications including infection. The burden of postoperative infection following ORIF techniques is a challenge many surgeons face and percutaneous techniques provide a possible solution. The ease by which one can manipulate the spatial arrangement of the calcaneus with percutaneous techniques provides a unique aspect in preserving native biomechanical properties and joint alignment. Additionally, arthrodiastasis may provide an additional benefit in preserving the articular structures.

Although there has not been complete agreement on which percutaneous technique is most successful, the delicate handling of tissue and spatial manipulation provide an excellent alternative to consider when approaching calcaneal fractures.

Dr. Dayton is an Assistant Professor in the College of Podiatric Medicine and Surgery at Des Moines University in Des Moines, Iowa.

Mr. Wolfe is a third-year student in the College of Podiatric Medicine and Surgery at Des Moines University.

Mr. Croy is a second-year student in the College of Podiatric Medicine and Surgery at Des Moines University.

Mr. Tocci is a second-year student in the College of Podiatric Medicine and Surgery at Des Moines University.

Mr. Richter is a second-year student in the College of Podiatric Medicine and Surgery at Des Moines University.

References
1. McGarvey WC, Burris MW, Clanton TO, Melissinos EG. Calcaneal fractures: indirect reduction and external fixation. Foot Ankle Int. 2006; 27(7):494-499.
2. 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.
3. Herscovici D Jr, Widmaier J, Scaduto JM, Sanders RW, Walling A. Operative treatment of calcaneal fractures in elderly patients. J Bone Joint Surg Am. 2005; 87(6):1260–1264.
4. Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma. 2004; 18(1):1-6.
5. Rammelt S, Amlang M, Barthel S, Zwipp H. Minimally-invasive treatment of calcaneal fractures. Injury. 2004; 35(suppl 2):SB55–SB63.
6. Stulik J, Stehlik J, Rysavy M, Wozniak A. Minimally invasive treatment of intra-articular fractures of the calcaneum. J Bone Joint Surg Br. 2006; 88(12):1634–1641.
7. Schepers T, Schipper I, Vogels L, Ginai A, Mulder P, Heetveld M, Patka P. Percutaneous treatment of displaced intra-articular calcaneal fractures. J Orthop Sci. 2007; 12(1):22–27.
8. Weber M, Lehmann O, Sagesser D, Krause F. Limited open reduction and internal fixation of displaced intra-articular fractures of the calcaneum. J Bone Joint Surg Br. 2008; 90(12):1608–1616.
9. Schuberth J, Cobb M, Talarico R. Minimally invasive arthroscopic-assisted reduction with percutaneous fixation in the management of intra-articular calcaneal fractures: a review of 24 cases. J Foot Ankle Surg. 2009; 48(3):315–322.
10. Kissel C, Husain Z, Cottom J, Scott R, Vest J. Early clinical and radiographic outcomes after treatment of displaced intra-articular calcaneal fractures using deltaframe external fixator construct. J Foot Ankle Surg. 2011; 50(2):135–140.
11. Tomesen T, Biert J, Frolke J. Treatment of displaced intra-articular calcaneal fractures with closed reduction and percutaneous screw fixation. J Bone Joint Surg Am. 2011; 93(10):920–928.
12. Pezzoni M, Salvi AE, Tassi M, Bruneo S. A minimally invasive reduction and synthesis method for calcaneal fractures: the “Brixian bridge” technique. J Foot Ankle Surg. 2009; 48(1):85-88.
13. 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):376-382.
14. 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.
15. 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. Rev Bras Ortop. 2016; 51(3):254-260.
16. Yeap EJ, Rao J, Pan CH, Soelar SA, Younger ASE. Is arthroscopic assisted percutaneous screw fixation as good as open reduction and internal fixation for the treatment of displaced intra-articular calcaneal fractures? Foot Ankle Surg. 2016; 22(3):164-169.
17. Roukis TS, Wunschel M, Lutz HP, Kirschner P, Zgonis T. Treatment of displaced intra-articular calcaneal fractures with triangular tube-to-bar external fixation: long-term clinical follow-up and radiographic analysis. Clin Podiatr Med Surg. 2008; 25(2):285-99, vii-viii.