SLR - October 2018 - Dalton M. Ryba
Reference: Rodriguez-Collazo E, Agyen J. PeriArticular Reconstruction for IntraArticular Calcaneal Fractures Utilizing the Ilizarov Method with Orthofix Truelok Circular External Fixator: A Technique Guide and Orthoplastic Considerations. Clin Surg. 2018; 3: 1998.Scientific Literature Review
Reviewed By: Dalton M. Ryba, DPM
Residency Program: John Peter Smith Hospital, Fort Worth, TX
Podiatric Relevance: The treatment spectrum of calcaneal fractures is broad and can be based on multiple considerations, including severity and acuity of injury, articular involvement, extent of soft-tissue compromise and patient demographics, including comorbid conditions, tobacco abuse, nutritional status and age. Historically, open reduction internal fixation has been reserved for intra-articular fractures with facet depression or marked comminution. The pendulum has shifted between operative and nonoperative treatment though, where recently the advocacy for minimal invasive techniques has increased. This is in part due to the associated postoperative complications as well as long-term outcomes when comparing treatment options. A recent study showed no statistically significant difference in operative versus nonoperatively treated displaced, intra-articular calcaneal fractures at a 10-year follow-up. The authors of this paper present the results of 47 patients (Sanders Type 3 or 4 fractures) treated with a minimally invasive technique utilizing external fixation, which has shown favorable results. This technique and associated outcomes provide the podiatric surgeon with evidence favoring minimally invasive surgical correction of the severe calcaneal fracture.
Methods: A level 4 retrospective cohort study was performed for all patients treated with minimally invasive indirect reduction and external fixation for 47 calcaneal fractures (27 Type 3, 20 Type 4) Outcomes were measured via AOFAS scores. The authors also describe their indications and technique for external fixation. Patient selection was reserved for those severely comminuted calcaneal fractures with significant and persistent edema, fracture blistering and/or lack of doppler signal to lateral calcaneal artery. The authors also favor this treatment modality in the comorbid patient, including those with diabetes, alcohol and/or tobacco abuse and vitamin or protein deficiencies.
Preoperative CT is utilized to evaluate injury severity in all cases. A Steinman pin in the tuber is utilized initially for axial traction (leg weighted with 25 lbs at 90 degrees or with traction table). A long tibial block consisting of two full rings is built and connected to a foot plate and dorsal half-ring distally with thread rods. Once reduction of the tuber is achieved, the Steinman pin is secured to the foot plate. Transosseous wires are placed at each segment, two at minimum, in 60-degree orientation and tensioned appropriately. A small incision is then made laterally to access the posterior facet. Here, the combination of an osteotome and a percutaneously placed Steinman pin is used to elevated the facet. An additional wire is placed juxta-articular to the facet for fixation. Bone graft is then utilized to back fill any void left inferiorly to the facet.
Results: Forty-seven patients (33 with severe medical comorbidity) were treated over a period of 32 months on average. Time in external fixator was 13 weeks on average. The mean postoperative AOFAS score was 81.25. No surgical dehiscence was reported. Three patients had superficial pin tract infections. Twelve patients required additional surgery, five for residual varus, seven for STJ arthrosis.
Conclusion: External fixation is a useful treatment modality in surgical management of severe calcaneal fractures in the compromised patient, with acceptable outcomes and reduced soft-tissue complications.