SLR - February 2013 - F. Hoffman
Reference: Beltran MJ, Collinge CA. Journal of Orthopedic Trauma. 2012 Nov;26:662-670.
Scientific Literature Review
Reviewed by: Farwa Hoffman, DPM
Residency Program: St. John Hospital and Medical Center - Detroit, Michigan
Podiatric Relevance:
High-energy open calcaneal fractures are uncommon injuries, but can be challenging as optimal treatment strategies for these injuries remains unclear. Current operative management of calcaneal fractures using a standard extensile lateral approach has shown to carry a high incidence of wound complications. Open calcaneal fractures are particularly at risk for complications with high grade soft tissue injuries. Due to the risk of complications with the staged standard lateral extensile approach for operative management, the authors performed a retrospective clinical review of patients with open calcaneal fractures treated with modern wound care, open reduction via the medial hindfoot wound with percutaneous screw fixation. The authors hypothesized that this approach would restore the calcaneal anatomy, allow for acceptable clinical outcomes, and offer reconstructive options while maintaining lower risks of complications.
Methods:
One hundred and twenty calcaneal fractures were treated between October 2001-July 2009. Inclusion criteria included patients with Gustilo and Anderson types II and III calcaneal fractures amenable to treatment with open reduction performed through the medial wound and percutaneous screw fixation. The following information was obtained and collected: patient demographics, injury characteristics, surgeries performed, complications encountered, and additional secondary surgical procedures required. Preoperative radiographs and computed tomography scans were analyzed and fractures were classified according to the OTA and Sanders classification systems. All patients received antibiotic therapy and early surgical debridement on admission. Repeat debridements were performed at 24-48 hour intervals. Open reduction was obtained through the medial wound and confirmed using lateral, Broden’s view, and axial radiographs. K-wires and screws were then placed percutaneously to maintain reduction placed posterior to anterior from the tuberosity into the anterior process, and a “kickstand” screw from the inferior posterior tuberosity into the posterior facet. Bohlers angle was measured preoperatively, intraoperatively or immediately postoperatively and at final follow-up. Postoperatively the operative extremity was splinted until the wounds were stable and converted to removable boot with range of motion exercises. Weight-bearing was initiated at 12 weeks. Postoperative follow-up including clinical and radiographic examination was performed at two weeks post-op and every six weeks thereafter until fracture healing was achieved. Clinical and radiographic results with functional outcome measures were assessed at a minimum of 12 months post injury. Limb-specific functional outcome scores were assessed using the American Orthopaedic Foot and Ankle Surgeon’s ankle-hindfoot instrument and Maryland Foot score, and whole person function was assessed using the Short Form 36 (SF-36). Data were analyzed with the Fischer exact test and Student t-test using SAS 9.1 statistical software with level of statistical significance defined as P < 0.05.
Results:
Nineteen of the 24 patients with an open calcaneal fracture met inclusion criteria and two were lost to follow-up leaving 17 patients for the study. Average follow-up was 45 months. All open wounds were medially oriented transversely. Associated ipsilateral foot/ankle injuries were present in eight cases including three ankle fractures, three talar fractures, one plafond fracture, and one midfoot fracture/dislocation. Patients averaged 2.2 surgical debridements before reduction of the calcaneus fracture. Four patients had wounds that healed with secondary intention including skin grafts or negative pressure system. No patients underwent subsequent amputation. One patient developed deep infection and one wound dehisced, both successfully treated with surgical debridement, local wound care, and appropriate antibiotics. Seven of the 17 patients (41 percent) required secondary surgical procedures including lateral exostectomy, screw removal, subtalar joint or triple arthrodesis. Eleven of 17 patients (65 percent) had moderate or severe subtalar joint arthrosis on follow-up radiographs. Preoperative Bohler angles averaged -14.6 degrees and postoperatively averaged +24.3 degrees. At final follow-up, the average Bohler’s angle was 13.1 degrees. Axial alignment immediately postoperatively averaged five degree valgus and three degree valgus at final follow-up. Union was obtained in 16 of 17 patients (94 percent). The daily visual analog pain score at final follow-up averaged 2.9. Loss of reduction as assessed by Bohler’s angle (P=0.45, 0.82), presence of subtalar arthrosis (P=0.79, 0.70), and need for hindfoot fusion (P=0.87, 0.60) did not seem to negatively affect the ankle-specific or general health function outcomes, respectively.
Conclusions:
Calcaneal fractures associated with high grade open wounds have increased incidence of infection, need for subsequent amputation, and poor functional outcomes. The authors of this study found a low incidence of wound complication in this series of 17 operatively treated high-grade open calcaneal fractures undergoing modern wound care, open reduction via the medial hindfoot wound with percutaneous screw fixation. The superficial wound complication rate of 11.7 percent with no deep infections compares well to previously reported deep infection rates of 11-72 percent of open calcaneus injuries treated by a number of methods. Avoiding an additional extensile approach to the hindfoot minimizes risk of complication. The approach in this series of open calcaneus fractures minimizes the risk of wound complications, however the restoration of calcaneal morphology might not be perfect. The anatomic reduction of the posterior facet from the medial side is more difficult and imperfectly reduced in the majority of the cases though it did not seem to affect functional outcomes. Prospective studies involving a larger patient base are needed before making a definitive conclusion regarding the technique.