Plating for intra-articular calcaneal fractures ... Is it an overkill?

SLR - October 2015 - Olga Shvets

Residency Program: SUNY Downstate

Podiatric Relevance: The optimal treatment of intra-articular calcaneal fractures remains unknown. There are currently no studies demonstrating definitive approaches to the treatment of displaced intra-articular calcaneal fractures. Based on the results of this study, minimally displaced intra-articular fractures can be treated more conservatively while displaced comminuted fractures may benefit from plating.

Methods: This was a comparative study of 30 acute displaced intra-articular calcaneal fractures. Excluded from the study were open fractures, extra articular fractures, and fractures older than two weeks. Fractures were classified using the Sander’s CT classification of intra articular calcaneal fractures. Conservative management was a below knee (BK) plaster cast or below knee slab depending on swelling and casts were removed seven-eight weeks. The operative group received ORIF via lateral approach. Angle of Gissane was described as a good indicator of restoration of articular surface anatomy. Patients were then placed in post op BK slabs for four-five weeks. Both groups were evaluated radiographically weekly for four weeks, then two months, six months and 12 months. Bohler’s angle, Heel varus angle, and Angle of Gissane were calculated, and Creighton-Nebraska (C-N) score was assessed in one year to determine functional outcome.

Results: In the operative group, the Gissane angle, Bohler’s ankle and Heel varus were statistically significantly improved. Functional outcome based on the C-N score showed similar outcomes without taking the fracture type into consideration. Three cases had wound dehiscence after plating.

Conclusion: Slightly better functional outcomes with plating of displaced and comminuted fractures were seen. The conservative group had a better outcome of minimally displaced fractures when compared to comminuted fractures. A trend was observed in which type of fracture would do well with conservative versus operative treatment. Type I fractures managed conservatively had an excellent outcome. Also, Type II and III fractures had almost similar outcome with operative and conservative management. Type IV fractures faired well with operative management. Bohler’s angle, Varus angulation and Gissane angle were restored in the operative group and could not be established in the conservative group. It was also determined that Bohler’s angle has prognostic importance in functional outcome. Lastly, in the case of displaced and comminuted calcaneal fractures, the aim should be surgical anatomical reduction and restoration of Bohler’s angle. There are a few limiting factors to the study, such as a small sample size and no long term follow up.