SLR - April 2012 - Jeffrey C. Lupica
References: Charles G. Kissel, Zeeshan S. Hussain, James A. Cottom, Ryan T. Scott, and Joshua Vest, Journal of Foot and Ankle Surgery 50(2011) 135-140.
Scientific Literature Review
Reviewed by: Jeffrey C. Lupica, DPM
Residency Program: Cleveland Clinic Foundation/Kaiser Permanente
Podiatric Relevance:
Intra-articular fractures of the calcaneus are complicated injuries that are often associated with long term pain, impairment, and often require further surgical repair. Surgical correction does not often guarantee long term correction and resolution of pain. This study is aimed to assess early clinical and radiographic postoperative findings of intra-articular calcaneal fractures following treatment by ligamentotaxis using a delta frame construct with a large fragment external fixator.
Methods:
Over a two year period, ten consecutive patients who presented to the podiatric surgery service at the Detroit Medical Center with closed, isolated, intra-articular calcaneal fractures were evaluated. Patients with contraindications to the surgical repair of their calcaneal fracture, and those with polytrauma, were excluded. Polytrauma was defined as any soft tissue or osseus injury to any other structure of the body or foot. The mean age of the patients was 45.8 +/- 12.3 years. Computerized tomography was used to visualize restoration of the STJ surface, and plain film radiograph were used to compare the restorative effects of distraction by ligamentotaxis.
Results:
Radiographic review showed that the mean calcaneal width was 4.81 +/-0.58cm at 5 cm superior to the plantar of the calcaneus preoperatively, and 4.37 +/- 0.62 cm postoperatively (P=.0077). The mean calcaneal height increased from 3.98 +/- 0.40cm preoperatively to 4.36 +/- 0.51 cm postoperatively (P = .0076). The mean calcaneal length increased from 7.45 +/- 0.67 cm preoperatively to 7.97 +/- 0.76 cm postoperatively (P = .0059). The mean Bohler’s angle increased from 20.80 +/- 8.27 degrees preoperatively to 25.70 +/- 5.21 degrees postoperatively (P = .0733). The mean Gissane’s angle decreased from 127.40 +/- 45.22 degrees preoperatively to 111.20 +/- 39.38 degrees postoperatively (P = .0059). At the final postoperative exam, mean 353.5 +/- 85.5 days, the mean total STJ range of motion was 19.00 +/- 4.50 degrees on the affected side and 34.40 +/- 4.58 degrees on the uninjured contralateral foot, and this difference was statistically significant (P = .005). The mean Maryland Foot score was 85.8 +/- 6.4 with 2 (20 percent) patients reporting excellent results (>90 points), 7 (70 percent) patients with good results (70-79 points), and none of the patients experienced poor results.
Conclusions:
The delta frame construct provides an alternative option with promising clinical and radiographic results by restoring calcaneal height, length, width and realigning the posterior subtalar joint facet while avoiding the complications often associated with ORIF. In this series, 90 percent of the patients experienced good or excellent results. One of the disadvantages of the delta frame construct is that in severely comminuted fractures the calcaneal tuberosity fragment may be too small for the pin to engage.