Chapter 61: Calcaneus Fractures

Michael P. Clare, Roy W. Sanders

Chapter Outline

Introduction to Calcaneus Fractures

Fractures of the calcaneus remain among the most challenging for the orthopedic surgeon. Calcaneal fractures account for approximately 2% of all fractures, with displaced intra-articular fractures comprising 60% to 75% of these injuries. Of patients with calcaneal fractures, 10% have associated spine fractures and 26% are associated with other extremity injuries.102,149 Calcaneal fractures are most commonly the result of a high-energy motor vehicle crash or a fall from a height. Ninety percent of calcaneal fractures occur in men between 21 and 45 years of age, with the majority being in industrial workers; thus, the economic implications of this injury are substantial.1,35,54,102,126,190 Improvements in seatbelts and the advent of airbags have dramatically improved survival rates from motor vehicle crashes; however, the energy transfer to the lower limbs as the engine collapses into the floorboard frequently results in highly complex fracture patterns with marked comminution and chondral damage, with significant long-term morbidity.146 Several authors have reported that patients may be totally incapacitated for up to 3 years and partially impaired for up to 5 years postinjury.1,54,102,126,190 Although modern surgical techniques have improved the outcome in many patients, controversy still exists regarding classification, treatment, operative technique, and postoperative management. 

Assessment of Calcaneus Fractures

Mechanisms of Injury for Calcaneus Fractures

Displaced intra-articular fractures of the calcaneus are typically the result of high-energy trauma, such as a fall from a height or a motor vehicle accident. The pattern of fracture lines and extent of comminution are determined by the position of the foot, the amount of force, and the porosity of the bone at the time of impact. Although controversy remains as to the exact mechanism of injury, there is a general consensus among most authors.27,54,102,125,178 
Essex-Lopresti54 believed the primary fracture line was initially produced laterally by the lateral process of the talus and the lateral edge of the talus, and then extended medially. He believed that at the moment of impact, the subtalar joint was forced into eversion, thus dividing the lateral wall and body of the calcaneus at the crucial angle of Gissane. The remaining force then dissipated into the sustentaculum medially (Figs. 61-1A and D). With continuation of the force, the fracture line could exit through the anterior process or calcaneocuboid joint, resulting in an anterolateral fragment. A secondary fracture line was created with increased force. If the force was directed posteriorly, the fracture would continue both posterior to and into the posterior facet, thereby producing a joint-depression–type fracture (Figs. 61-1B,C). If the force was directed axially, a tongue-type fracture was produced (Figs. 61-1E-F). 
Figure 61-1
Mechanism of injury according to Essex-Lopresti.
 
(A–C) Joint depression. (D–F) Tongue.
(A–C) Joint depression. (D–F) Tongue.
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Figure 61-1
Mechanism of injury according to Essex-Lopresti.
(A–C) Joint depression. (D–F) Tongue.
(A–C) Joint depression. (D–F) Tongue.
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Carr et al.27 reported on experimentally created, intra-articular calcaneal fractures in a cadaveric model. Two primary fracture lines were identified. One fracture line divided the calcaneus into medial and lateral portions, with the fracture either extending into the calcaneocuboid joint or exiting in the anterior facet. The second primary fracture line divided the calcaneus into anterior and posterior portions, beginning laterally at the angle of Gissane and extending medially (Fig. 61-2). This second fracture line often continued medially to divide the middle facet; laterally, the fracture line extended inferiorly, either toward the plantar surface or anteriorly. These two primary fracture lines produced a combination of fracture patterns, including both tongue-type and joint-depression–type fractures, as well as the commonly observed anterolateral and superomedial fragments, thus confirming the work of Essex-Lopresti and others.54,164,196 
Figure 61-2
Mechanism of injury according to Carr.27
 
1: Coronally oriented fracture line dividing calcaneus into anterior and posterior portions; 2: Sagittally oriented fracture line dividing calcaneus into medial and lateral portions; 3: Anterolateral fragment
1: Coronally oriented fracture line dividing calcaneus into anterior and posterior portions; 2: Sagittally oriented fracture line dividing calcaneus into medial and lateral portions; 3: Anterolateral fragment
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Figure 61-2
Mechanism of injury according to Carr.27
1: Coronally oriented fracture line dividing calcaneus into anterior and posterior portions; 2: Sagittally oriented fracture line dividing calcaneus into medial and lateral portions; 3: Anterolateral fragment
1: Coronally oriented fracture line dividing calcaneus into anterior and posterior portions; 2: Sagittally oriented fracture line dividing calcaneus into medial and lateral portions; 3: Anterolateral fragment
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Associated Injuries with Calcaneus Fractures

Up to 50% of patients with calcaneus fractures may have other associated injuries, including lumbar spine fractures or other fractures of the lower extremities, such as in the ipsilateral or contralateral tibial plateau, tibial pilon, or talar neck; intuitively these associations are more common in higher-energy trauma.29,54,149 Clearly, the more energy involved, the greater the likelihood of other associated injuries. It is estimated that 10% of patients with calcaneus fractures also have lumbar spine fractures, and 25% have associated lower extremity injuries.115 Thus, a high index of suspicion must be maintained for these associated injuries, and appropriate diagnostic evaluation should be completed where necessary. 

Signs and Symptoms of Calcaneus Fractures

Injury to the Soft Tissue Envelope

The severity of fracture displacement and the extent of soft tissue disruption are proportional to the amount of force and energy involved in producing the injury. Lower-energy injuries with minimal force produce only mild swelling and ecchymosis, whereas higher-energy injuries result in severe soft tissue disruption and may result in an open fracture. Patients typically experience severe pain overlying the fracture, which is related to the extent of bleeding into the tightly enveloped soft tissue surrounding the heel. Several hours following the injury, soft tissue swelling in the hindfoot is typically so severe that a distinct lack of skin creases in the area is noted. 
Skin Blisters.
Fracture blisters may appear anywhere about the foot secondary to swelling.6567,187 Blisters are a reflection of the mount of energy involved, and result from shear stress on the skin, which produces a cleavage at the dermal–epidermal junction. The fluid within the blister represents a sterile transudate, and remains clear if the dermis retains some epidermal cells; the fluid becomes bloody if the dermis is completely devoid of epidermal cells.66 Acute surgical incisions should generally be modified to avoid areas of blistered skin. With respect to calcaneus fractures, definitive surgical management should be delayed until the blister has resolved and the involved skin has fully reepithelialized. This is especially true with blood-filled blisters, which are associated with a markedly increased risk of infection if an incision is placed through an area of incompletely recovered skin. 
Giordano65 prospectively evaluated various treatment methods for blister management, including aspiration of the blister, unroofing the blister with subsequent application of Silvadene cream or coverage with a nonadherent dressing, or leaving the blister intact and covered by loose gauze or exposed to air. Although there was no significant difference in the outcome of the various soft tissue management techniques, wound healing complications developed in two patients who had incisions through blood-filled blisters. In addition, Varela et al.186 retrospectively reviewed 53 cases and identified 2 cases with major wound infections secondary to incisions passing through the blister. They noted colonization with normal skin flora in 11 ruptured vesicles soon after rupture of the blister, which persisted until reepithelialization of the area. 
Compartment Syndrome.
There are four compartments within the foot: The medial, lateral, central, and interosseous compartments. The central compartment is divided into two separate compartments by a transverse septum in the hindfoot: The superficial compartment containing flexor digitorum brevis muscle, and the deep or calcaneal compartment containing the quadratus plantae and the lateral plantar nerve.55 The calcaneal compartment communicates directly with the deep posterior compartment of the lower leg.106 
A compartment syndrome develops when increased pressure within a closed fascial space affects pulse pressure such that arterial flow is decreased. This classically produces pain out of proportion to the injury, not unlike that typically associated with a calcaneal fracture. Thus, care must be taken to ensure that the severe pain associated with the fracture is not caused by a compartment syndrome of the foot, particularly in the calcaneal compartment. A self-contained needle manometer system (Quikstik; Stryker, Kalamazoo, MI) is most commonly used to measure compartment pressures. Most authors recommend fasciotomy when the compartment pressure rises to within 10 to 30 mm Hg of the patient’s diastolic pressure.55,117,120 
The difficulty generally lies in distinguishing pain as a result of the fracture from pain resulting from a compartment syndrome, which can result in a delay in diagnosis. Even if a timely diagnosis of compartment syndrome is made, there is controversy as to whether or not to actually treat it, presumably due to the additional incisions associated with acute fasciotomy and the implications with regard to soft tissue healing, as well as the relative unfamiliarity of the compartmental anatomy of the foot among trauma surgeons. The long-term sequelae of an unrecognized compartment syndrome in the foot can include clawtoe deformities with permanent loss of function, contracture, weakness, and sensory disturbances. 
Skin Necrosis Secondary to Displaced Tongue Fractures.
When a tongue fragment is significantly displaced, pressure on the posterior skin may occur, causing necrosis if left untreated. Gardner et al.62 recently presented a series of 137 tongue fractures with 21 cases exhibiting posterior skin necrosis. In those fractures treated emergently with percutaneous reduction and temporary Kirschner wire (K-wire) stabilization, soft tissue compromise did not occur. The authors concluded that because of the high incidence of posterior skin compromise in tongue-type calcaneus fractures, consideration should be given to immediate percutaneous reduction and temporary stabilization, plantarflexion splinting, and close monitoring (Fig. 61-3). 
Figure 61-3
 
A: Tongue-type fracture. Note how close the tuberosity is to the skin (asterisk). B: Clinical photograph showing pressure on posterior heel (black arrow).
A: Tongue-type fracture. Note how close the tuberosity is to the skin (asterisk). B: Clinical photograph showing pressure on posterior heel (black arrow).
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Figure 61-3
A: Tongue-type fracture. Note how close the tuberosity is to the skin (asterisk). B: Clinical photograph showing pressure on posterior heel (black arrow).
A: Tongue-type fracture. Note how close the tuberosity is to the skin (asterisk). B: Clinical photograph showing pressure on posterior heel (black arrow).
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Open Fractures.
Open fractures of the calcaneus are distinct injuries relative to closed fractures and thus require different treatment (Figs. 61-4A-B).78 Between 7.7% and 17% of fractures to the calcaneus are open.11,13,78 They are generally associated with a higher complication rate than their closed counterparts, including deep infection, osteomyelitis, and possible need for amputation.13,100,118,124,154 Coughlin,35 in a review of calcaneal fractures in industrial workers, also found that open fractures were associated with increase in the total cost of treatment and time off from work. 
Figure 61-4
Gustilo type IIIB open calcaneal fracture.
 
A: Pre-debridement. Note extruded bone (white arrow). B: Extruded bone is significant portion of posterior facet articular surface on soft tissue hinge (black arrow).
A: Pre-debridement. Note extruded bone (white arrow). B: Extruded bone is significant portion of posterior facet articular surface on soft tissue hinge (black arrow).
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Figure 61-4
Gustilo type IIIB open calcaneal fracture.
A: Pre-debridement. Note extruded bone (white arrow). B: Extruded bone is significant portion of posterior facet articular surface on soft tissue hinge (black arrow).
A: Pre-debridement. Note extruded bone (white arrow). B: Extruded bone is significant portion of posterior facet articular surface on soft tissue hinge (black arrow).
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Open fractures of the calcaneus may present with a puncture wound medially from a spike of bone protruding from the medial wall of the calcaneus or may present with a more substantial wound with significant soft tissue disruption, typically laterally. When a calcaneal fracture is associated with an injury to the soft tissue envelope, it is important to categorize the wound, noting its size and location as well as its Gustilo type.72,73 The fracture is then classified, and together these factors can give the surgeon an estimation of the severity of the injury and its eventual outcome, as all of these factors play a role in prognosis.4,11,13,78,94 
Treatment should include irrigation with 9 L of normal saline and debridement of the wound with stabilization of the fracture to protect the soft tissues. When in doubt regarding the degree of soft tissue trauma, closed reduction and percutaneous stabilization may be performed to realign the extremity. This may be with K-wires, an external fixator, or both. Standard antibiotic prophylaxis is begun, and subsequent treatment must be tailored to the injury, but early and aggressive internal fixation should be avoided as the additional operative trauma will compromise the limb, and amputation may result.142 Three or more months may be required to allow the soft tissues to heal sufficiently before surgical salvage can be contemplated, and these subsequent procedures are invariably for treatment of a severe calcaneal malunion. 

Imaging and Other Diagnostic Studies for Calcaneus Fractures

Plain Radiography

The initial radiographic evaluation of the patient with a suspected calcaneal fracture includes a lateral radiograph of the hindfoot, an anterior posterior radiograph of the foot, a Harris heel view, and an ankle series. In this way, all associated fractures, subluxations, and/or dislocations can be diagnosed. Because of the association with lumbar spine fractures, routine lumbar spine radiographs should also be obtained.79 If the radiographs reveal an intra-articular component to the calcaneal fracture, computed tomography (CT) scanning is indicated. Multiple radiographic projections have been described; however, most of these views are hard to read and even more difficult to consistently reproduce.6,84,164,187 In contrast, CT evaluation, when interpreted correctly, provides a wealth of data for both diagnosis and treatment. 
Lateral Radiographs.
Traction trabeculae extending from the inferior cortex of the calcaneus combine with compression trabeculae supporting the posterior and anterior articular facets. The area between these trabeculae creates a space known as the neutral triangle75 (Fig. 61-5). The lateral radiograph of the hindfoot demonstrates two important angles: The tuber angle of Bohler and the crucial angle of Gissane (Fig. 61-6). The tuber angle of Böhler is composed of a line drawn from the highest point of the anterior process of the calcaneus to the highest point of the posterior facet and a line drawn tangential to the superior edge of the tuberosity.17 The angle is normally between 20 and 40 degrees; a decrease in this angle indicates that the weight-bearing posterior facet of the calcaneus has collapsed, thereby shifting body weight anteriorly. McLaughlin109 determined that reduction or reversal of this angle indicates only the degree of proximal displacement of the tuberosity and thus can be decreased in both intra or extra-articular fractures, limiting its usefulness.170 The crucial angle of Gissane is formed by two strong cortical struts extending laterally: One along the lateral margin of the posterior facet and the other extending anterior to the beak of the calcaneus. These cortical struts form an obtuse angle54 and are visualized directly beneath the lateral process of the talus.158 
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Figure 61-5
Neutral triangle.
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Figure 61-6
Anatomic angles for evaluation of fracture displacement and surgical reduction.
 
A: Crucial angle of Gissane. B: Tuber angle of Böhler.
A: Crucial angle of Gissane. B: Tuber angle of Böhler.
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Figure 61-6
Anatomic angles for evaluation of fracture displacement and surgical reduction.
A: Crucial angle of Gissane. B: Tuber angle of Böhler.
A: Crucial angle of Gissane. B: Tuber angle of Böhler.
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The lateral radiograph should confirm the diagnosis of a calcaneal fracture. Radiographs of intra-articular fractures usually show a loss in the height of the posterior facet, with a decrease in the angle of Bohler and an increase in that of Gissane, but only if the entire facet is separated from the sustentaculum and depressed. If only the lateral half of the posterior facet is fractured and displaced, a split in the articular surface will be seen as a “double density” and Bohler’s and Gissane’s angles may appear to be normal153 (Fig. 61-7). The articular surface can be found within the body of the calcaneus; usually, it is rotated 90 degrees in relation to the remainder of the subtalar joint. The lateral radiograph also indicates whether the fracture is of the joint-depression or tongue-type according to the classification of Essex-Lopresti.54 
A: Lateral radiograph (red arrows). B: Intraoperative correlation (black arrows).
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Figure 61-7
The “double density”; a joint-depression–type fracture where the lateral portion of the joint is impacted but both Böhler and Gissane angles are normal.
A: Lateral radiograph (red arrows). B: Intraoperative correlation (black arrows).
A: Lateral radiograph (red arrows). B: Intraoperative correlation (black arrows).
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Other Plain Radiographic Views.
The anteroposterior radiograph of the foot shows extension of the fracture line into the calcaneocuboid joint (Fig. 61-8). This radiograph provides very little information and usually may be omitted. The Harris axial radiograph of the heel allows visualization of the joint surface as well as loss of height, increase in width, and angulation of the tuberosity fragment (Fig. 61-9). Unfortunately, this radiograph is very difficult to obtain in the acute setting because of pain. 
Figure 61-8
Anteroposterior view of the foot showing a fracture entering calcaneocuboid joint (black arrow).
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Figure 61-9
Harris axial view of the heel.
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Tomograms, once routinely utilized, are now rarely indicated, as they provide no additional information when CT is available, and they expose the patient to increased doses of radiation.74 Deutsch et al.44 pointed out that tomograms may fail to show the extent of articular incongruity. 
Broden’s view, however, is a reproducible means of demonstrating the articular surface of the posterior facet on plain radiographs.22 This view, known as Broden Projection I, is obtained with the patient supine and the x-ray cassette under the leg and the ankle. The foot is in neutral flexion, and the leg is internally rotated 30 to 40 degrees. The x-ray beam then is centered over the lateral malleolus, and four radiographs are made with the tube angled 40, 30, 20, and 10 degrees toward the head of the patient. These radiographs show the posterior facet as it moves from posterior to anterior; the 10-degree view shows the posterior portion of the facet, and the 40-degree view shows the anterior portion (Fig. 61-10). Although this view is difficult to explain to, and obtain from, a technician, a mortise view of the ankle will recreate this view perfectly. Therefore, an ankle series should be requested. Furthermore, this view should be obtained intraoperatively using the fluoroscope and is indispensible to verify the reduction of the articular surface.91 
Figure 61-10
Broden view of the subtalar joint.
 
A: Correct way to obtain view. B: Simplest way to obtain view is by taking a mortise view of the ankle.
 
(A, Redrawn from Burdeaux BD Jr. The medical approach for calcaneal fractures. Clin Orthop Relat Res 1993;290: 96–107.)
A: Correct way to obtain view. B: Simplest way to obtain view is by taking a mortise view of the ankle.
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Figure 61-10
Broden view of the subtalar joint.
A: Correct way to obtain view. B: Simplest way to obtain view is by taking a mortise view of the ankle.
(A, Redrawn from Burdeaux BD Jr. The medical approach for calcaneal fractures. Clin Orthop Relat Res 1993;290: 96–107.)
A: Correct way to obtain view. B: Simplest way to obtain view is by taking a mortise view of the ankle.
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Computed Tomography Scanning

CT scanning has vastly improved the understanding of calcaneal fractures and has subsequently allowed for consistent analysis of treatment results. CT images are obtained in the axial, 30-degree semicoronal, and sagittal planes. The coronal views provide information about the articular surface of the posterior facet, the sustentaculum, the overall shape of the heel, and the position of the peroneal and flexor hallucis tendons. The axial views reveal information about the calcaneocuboid joint, the anteroinferior aspect of the posterior facet, and the sustentaculum. Sagittal reconstruction views provide additional information as to the posterior facet, the calcaneal tuberosity, and the anterior process (Figs. 61-11 and 61-12). 
Figure 61-11
Axial (coronal) CT scan views of the calcaneus.
 
Note that the lateral fragment (arrow) gets smaller and rotates as the sections move from posterior (A) to anterior (D). S, sustentaculum.
Note that the lateral fragment (arrow) gets smaller and rotates as the sections move from posterior (A) to anterior (D). S, sustentaculum.
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Figure 61-11
Axial (coronal) CT scan views of the calcaneus.
Note that the lateral fragment (arrow) gets smaller and rotates as the sections move from posterior (A) to anterior (D). S, sustentaculum.
Note that the lateral fragment (arrow) gets smaller and rotates as the sections move from posterior (A) to anterior (D). S, sustentaculum.
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Figure 61-12
Transverse CT scan sections showing lateral fragment (white arrow) rotated such that joint surface is parallel to calcaneocuboid joint (black arrow).
*, Anterolateral wall fragment.
*, Anterolateral wall fragment.
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The use of three-dimensional CT scanning for intra-articular calcaneal fractures was recently evaluated in several studies.3,184 Although this is an interesting modality, the definition of the articular surface was not sufficient to assist in preoperative planning or to justify the costs. Vannier et al.184 concluded that the diagnostic value of three-dimensional CT was equivalent to that of conventional two-dimensional CT. 

Classification of Calcaneus Fractures

In the past, the inability to accurately classify calcaneal fractures has contributed to the difficulty in treating these injuries. Classification systems are designed to facilitate communication among surgeons, plan operative procedures, and assist in determining outcomes. Historically, calcaneal fracture classification systems based on plain radiographs existed but were of limited use.54,125,149,188,190 With the advent of CT scanning, standardization of imaging techniques has allowed for the development of modern classification systems, which has greatly enhanced the management of calcaneal fractures. 

Classifications Based on Plain Radiography

Although described as early as 1851 by Malgaigne,105 Essex-Lopresti in 195254 popularized the concept of two distinct fracture patterns: A tongue-type fracture, where the articular fragment remained attached to a tuberosity fragment, and a joint-depression–type fracture, in which the articular fragment was separate from the adjacent tuberosity. The advantage of this distinction was that the surgeon could accurately choose the correct treatment method. Unfortunately, this classification provided little prognostic information. Several other authors described fracture patterns and classifications, but these systems were in essence variations of the Essex-Lopresti classification.7,63,188,190 
In 1975, Soeur and Remy164 reported on a new classification system, which was uniquely based on the number of articular bony fragments as determined on anteroposterior, lateral, and Harris axial heel views. First-degree fractures were nondisplaced shear-type fractures with widening of the joint surface. Second-degree fractures included secondary fracture lines, resulting in a minimum of three fragments, two of which included the articular surface. Third-degree fractures were highly comminuted such that they could not be classified, and therefore the authors could not specify if the comminution referred to the body or the articular surface of the posterior facet. Although they proposed that displaced intra-articular fractures should be managed surgically with internal fixation, their results could not be correlated to their classification. 

Classifications Based on CT Scanning

The use of CT scanning in the diagnosis and treatment of calcaneal fractures was first described by Segal et al.160 and was also used by Stephenson.171 Zwipp et al.,196 however, were the first to apply information provided on CT evaluation into a rational understanding of the injury. In his classification, the entire calcaneus was considered, with a total of five possible fragments, similar to the systems of Essex-Lopresti and Soeur and Remy, but based on CT scan data54,164 (Fig. 61-13). Although surgical outcomes were evaluated, no prognosis based on fracture classification was made. 
Figure 61-13
Zwipp CT scan classification of calcaneal fractures.
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Crosby and Fitzgibbons37 were the first authors to correlate clinical outcome (albeit as a result of nonoperative treatment) with a fracture classification system based on CT evaluation. They divided their fractures into three types based on the articular surface displacement: Type I, nondisplaced; type II, displaced; and type III, comminuted. Subsequently, Sanders developed a CT scan classification system based on the number and location of articular fracture fragments alone.152,154 This was the natural progression of fracture patterns identified by Soeur and Remy.164 The classification was found to be useful in determining both treatment methods and prognosis after surgical fixation.154 Many additional authors have since used this classification and found it to be prognostic with respect to outcome as well.5,39,60,77,114,174,176 During the analysis of the results of operative treatment, it became clear to Sanders et al.154 that the body of the calcaneus could be restored surgically to virtual anatomic shape by using a lateral approach, regardless of the degree of comminution. Because the prognostic factor for outcome was the articular reduction and the degree of cartilage damage, the classification has been purposely limited to articular displacement. 
The articular fracture classification system of Sanders et al.154 is based on images in the coronal plane (Fig. 61-14). Although all coronal sections were analyzed, the original classification arbitrarily used one CT scan view with the widest undersurface of the posterior facet of the talus (in reality, the entire CT scan should be evaluated to watch fracture lines move in and out of plane, and to determine which are artifact, and which are real). The talus was divided into three equal columns by two lines that were then extended across the calcaneal posterior facet; with the addition of a third line, just medial to the medial edge of the posterior facet, the posterior facet of the calcaneus could be arbitrarily divided the into three potential fragments: Medial, central, and lateral. These fragments plus the sustentaculum resulted in a total of four potential articular pieces. All nondisplaced articular fractures (less than 2 mm), regardless of the number of fracture lines, were considered type I fractures; type II fractures were two-part fractures of the posterior facet. Three types—IIA, IIB, and IIC—existed, based on the location of the primary fracture line. Type III fractures were three-part fractures that usually featured a centrally depressed fragment. Types included IIIAB, IIIAC, and IIIBC, and again were based on the location of the primary fracture line. Type IV fractures, or four-part articular fractures, were highly comminuted and often had more than four articular fragments. Although the subclassification of articular fracture lines by medial-to-lateral location is important prognostically, most surgeons simply identify the number of articular fragments138 (Fig. 61-15). 
Figure 61-14
Sanders CT scan classification of calcaneal fractures.
 
(Redrawn from: Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000;82A:225–250, with permission.)
(Redrawn from: Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000;82A:225–250, with permission.)
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Figure 61-14
Sanders CT scan classification of calcaneal fractures.
(Redrawn from: Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000;82A:225–250, with permission.)
(Redrawn from: Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000;82A:225–250, with permission.)
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Figure 61-15
CT scans of various fracture patterns according to Sanders.
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Originally, this classification system was described for joint-depression fractures exclusively. With the addition of the initial lateral radiograph, however, the surgeon can determine whether the fracture is a joint-depression or a tongue-type fracture. Once this is established, tongue-type fractures can be classified using this system as well. The true extra-articular tongue is typically a type IIC, where the entire facet is displaced but intact. If the tongue fracture extends intra-articularly, the fracture is typically a type IIB. In addition, tongue-type fractures with joint-depression components (mixed fractures) can clearly be evaluated using this CT scan classification. It is important to understand and identify these tongue variants, as the treatment methods will be dictated by the presence or absence of an intra-articular component (Figs. 61-16 and 61-17). 
Figure 61-16
The tongue fractures including the intra-articular patterns (as variants of the joint-depression patterns described by Sanders).
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Figure 61-17
True intra-articular tongue fracture (type IIB).
 
Plain radiographs are unable to determine whether the fracture involves the posterior facet (A, B). Semicoronal and transverse CT scans verify intra-articular displacement (C, D). Note black arrows, indicating intra-articular fracture, and white arrows, indicating the intact lateral wall component typical of tongue fractures.
Plain radiographs are unable to determine whether the fracture involves the posterior facet (A, B). Semicoronal and transverse CT scans verify intra-articular displacement (C, D). Note black arrows, indicating intra-articular fracture, and white arrows, indicating the intact lateral wall component typical of tongue fractures.
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Figure 61-17
True intra-articular tongue fracture (type IIB).
Plain radiographs are unable to determine whether the fracture involves the posterior facet (A, B). Semicoronal and transverse CT scans verify intra-articular displacement (C, D). Note black arrows, indicating intra-articular fracture, and white arrows, indicating the intact lateral wall component typical of tongue fractures.
Plain radiographs are unable to determine whether the fracture involves the posterior facet (A, B). Semicoronal and transverse CT scans verify intra-articular displacement (C, D). Note black arrows, indicating intra-articular fracture, and white arrows, indicating the intact lateral wall component typical of tongue fractures.
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Preoperative planning also requires evaluation of the body of the calcaneus on CT scans. Miric and Paterson114 described the patterns of comminution of the anterior process (Fig. 61-18). These typically mirror the lines that divide the articular surface and are best seen on the transverse CT scan. Importantly, they reaffirmed the need to obtain an anatomic reduction of the body of the calcaneus as well as the joint. Finally, on the transverse CT scan, a medial-to-lateral extra-articular fracture at the level of the anterior edge of the posterior facet can often be seen, as originally described by Carr et al.27 This fracture line is important to find, as its presence indicates that the medial component of the joint can be rotated in a plantar direction and must be brought out from under the anterior process to obtain an anatomic joint reduction. It is our belief that the main limitation of this classification, as well as all CT scanning at the present time (even with the advent of reformatting techniques), is that it cannot determine whether the sagittally split fragment is additionally fractured in the coronal plane. Often, this cannot be determined until the fracture is surgically treated, and occasionally not until the fragment separates while being repositioned. 
Figure 61-18
Miric and Patterson’s114 schematic representation of the periarticular fracture extension lines into the anterior process (A) and around the posterior facet (B).
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Figure 61-18
Miric and Patterson’s114 schematic representation of the periarticular fracture extension lines into the anterior process (A) and around the posterior facet (B).
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Outcome Measures for Calcaneus Fractures

There is unfortunately no consensus as to the most optimum method for outcomes assessment as it relates to calcaneus fractures. Scoring systems historically utilized include those specific to the involved limb: (1) American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot Score; (2) Maryland Foot Score; (3) Foot Function Index; and (4) Musculoskeletal Functional Assessment. Generalized outcome measures (SF-36) have also been used. 

Pathoanatomy and Applied Anatomy Relating to Intra-Articular Calcaneus Fracture

In the event of a displaced intra-articular calcaneal fracture, the loss of height through the calcaneus results in a shortened and widened heel, classically with varus malalignment of the tuberosity. This loss of height is reflected in a decreased tuber angle of Böhler, such that the normal declination of the talus is diminished and the talus becomes relatively more horizontal, which leads to secondary loss of ankle dorsiflexion. As the superolateral fragment of the posterior facet is impacted plantarward, the thin lateral wall explodes laterally just posterior to the crucial angle of Gissane. This lateral wall expansion may trap the peroneal tendons against the lateral malleolus and also affect subtalar motion; in some cases a violent contracture of the peroneal tendons may avulse the tendon sheath from the fibula, resulting in an avulsion fracture of the lateral malleolus and dislocation of the peroneal tendons. The anterior process typically displaces superiorly, which directly limits subtalar joint motion by impinging against the lateral process of the talus. 
Clarification of fragment terminology is necessary to understand the pathoanatomy of displaced intra-articular calcaneal fractures (Fig. 61-19). The anterolateral fragment encompasses the lateral wall of the anterior process, is typically pyramidal in shape and may include a portion of the calcaneocuboid articular surface. The anterior main fragment is the large fragment anterior to the primary fracture line, which usually includes the anterior portion of the sustentaculum and anterior process. The superomedial fragment, also known as the sustentacular or constant fragment, is the fragment of variable size found posterior to the primary fracture line; this fragment almost always remains attached to the talus through the deltoid ligament complex and is therefore stable. The superolateral fragment, also referred to as the semilunar or comet fragment, is the lateral portion of the posterior facet which is sheared from the remaining posterior facet in joint-depression fractures. The tongue fragment refers to the superolateral fragment that remains attached to a portion of the posterior tuberosity including the Achilles tendon insertion, and is found in tongue-type fractures. The posterior main fragment represents the posterior tuberosity. 
Figure 61-19
Pathoanatomy of a joint-depression calcaneal fracture.
 
A: Axial/transverse view. Note lateral wall expansion (white arrow). B: Sagittal view. C: Coronal view. Note dislocated peroneal tendons (white arrow). AL: anterolateral fragment; AM: anterior main fragment; PM: posterior main (tuberosity) fragment; SL: superolateral fragment; SM: superomedial (sustentacular) fragment.
A: Axial/transverse view. Note lateral wall expansion (white arrow). B: Sagittal view. C: Coronal view. Note dislocated peroneal tendons (white arrow). AL: anterolateral fragment; AM: anterior main fragment; PM: posterior main (tuberosity) fragment; SL: superolateral fragment; SM: superomedial (sustentacular) fragment.
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Figure 61-19
Pathoanatomy of a joint-depression calcaneal fracture.
A: Axial/transverse view. Note lateral wall expansion (white arrow). B: Sagittal view. C: Coronal view. Note dislocated peroneal tendons (white arrow). AL: anterolateral fragment; AM: anterior main fragment; PM: posterior main (tuberosity) fragment; SL: superolateral fragment; SM: superomedial (sustentacular) fragment.
A: Axial/transverse view. Note lateral wall expansion (white arrow). B: Sagittal view. C: Coronal view. Note dislocated peroneal tendons (white arrow). AL: anterolateral fragment; AM: anterior main fragment; PM: posterior main (tuberosity) fragment; SL: superolateral fragment; SM: superomedial (sustentacular) fragment.
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Fracture–Dislocations of the Calcaneus

Fractures of the calcaneus generally occur with impaction of the superolateral fragment into the body of the calcaneus, creating either a tongue-type or joint-depression–type fracture.62 Occasionally, the superolateral fragment remains part of the lateral wall, such that the entire lateral fragment and the posterior tuberosity dislocate laterally (Fig. 61-20). In this injury, the superolateral fragment with the attached posterior tuberosity is shifted laterally and driven into the talofibular joint, often fracturing the lateral malleolus and dislocating the peroneal tendons. The lateral ligamentous complex of the ankle is often disrupted, causing inversion of the ankle and hindfoot with recoil of the injury, which is seen radiographically as varus tilt of the talus.16,36,5052,139,183 
Figure 61-20
Fracture–dislocation of the calcaneus.
 
A: Lateral radiograph clearly demonstrating dislocation of lateral calcaneus (black arrows). B: Mortise view of ankle demonstrating fibula abutment (white arrow) with rupture of lateral ligaments and subluxation of ankle (black arrow). C: Coronal CT scan demonstrating same findings as in (B).
A: Lateral radiograph clearly demonstrating dislocation of lateral calcaneus (black arrows). B: Mortise view of ankle demonstrating fibula abutment (white arrow) with rupture of lateral ligaments and subluxation of ankle (black arrow). C: Coronal CT scan demonstrating same findings as in (B).
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Figure 61-20
Fracture–dislocation of the calcaneus.
A: Lateral radiograph clearly demonstrating dislocation of lateral calcaneus (black arrows). B: Mortise view of ankle demonstrating fibula abutment (white arrow) with rupture of lateral ligaments and subluxation of ankle (black arrow). C: Coronal CT scan demonstrating same findings as in (B).
A: Lateral radiograph clearly demonstrating dislocation of lateral calcaneus (black arrows). B: Mortise view of ankle demonstrating fibula abutment (white arrow) with rupture of lateral ligaments and subluxation of ankle (black arrow). C: Coronal CT scan demonstrating same findings as in (B).
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The fracture–dislocation of the calcaneus was first described in 1977 by Biga and Thomine.16 They observed four cases where the fracture line was in the sagittal plane with only two fragments. An anterior and medial fragment maintained its normal relationship with the talus, but the posterior and lateral fragment became dislocated laterally underneath the fibular malleolus. They called this a fracture–dislocation of the calcaneus, and suggested that treatment always be surgical by open reduction and screw fixation. They noted that two of the four patients who were not operated on had poor results. 
Court-Brown et al.36 described two patients with calcaneal fracture–dislocation where the calcaneus split into a small anteromedial fragment and a larger posterolateral fragment. The authors believed that closed reduction was impossible and open reduction essential. Ebraheim et al.60 described an additional two cases. In addition to the findings already mentioned, they also noted that the peroneal tendons were dislocated. CT scans also showed obvious varus talar tilt, indicating ankle instability. Again, these authors believed that conservative treatment by casting or early range of motion was contraindicated, and that a lateral approach with ORIF should be performed. 
Eastwood et al.50 reported four cases in which radiographic features of a fracture of the lateral malleolus and talar tilt of varying severity were associated with a displaced fracture of the calcaneus. In two cases, the initial diagnosis was of a primary ankle injury, which led to inappropriate initial management. Gross fracture subluxation of the posterior subtalar joint had occurred in all four cases but could only be fully appreciated on CT scan. ORIF of the calcaneus led to spontaneous reduction of the talar displacement. The authors noted that a swollen hindfoot, talar tilt, and a flake fracture of the lateral malleolus must alert clinicians to the possibility of a calcaneal fracture–dislocation. Ebraheim et al.,51 in a subsequent report, evaluated another 11 calcaneal fracture–dislocations. These injuries all had an intra-articular calcaneal fracture, lateral subluxation or dislocation of the posterior facet, peroneal tendon subluxation, subluxation of the talus in the ankle mortise, and complete disruption of the anterior talofibular and calcaneal fibular ligaments or fracture of the lateral malleolus. 
Turner and Haidukewych185 reported on two calcaneal fractures associated with locked dislocation of the posterior facet. Both were treated with minimally invasive open reduction and percutaneous screw fixation of the fragment with cannulated screws, with an uncomplicated course. Finally, Randall and Ferretti139 recently presented a case report of a lateral subtalar joint dislocation with an associated calcaneal fracture that was not evident on plain film radiographs but clearly delineated on subsequent CT scans. 
When evaluating a calcaneal fracture, the first suggestion that a fracture–dislocation exists is a dislocation of the peroneal tendons, which can be palpated anterior to the fibular malleolus. Plain radiographs may show the calcaneal pathology, but careful inspection will reveal a small degree of varus talar tilt. CT scans clearly show the fracture–dislocation, generally associated with severe hindfoot varus, the peroneal dislocation, and the ankle ligamentous disruption. All pathology must be addressed surgically through a lateral approach. 
The calcaneal fracture component to these injuries is usually a simple two-part split fracture. Because the articular surfaces are still part of their respective tuberosity fragments, if the dislocation can be reduced, the fracture usually will recoil into an anatomic position. To accomplish this, however, reduction must occur sooner, rather than later. Therefore, when a fracture–dislocation is suspected, CT scans should be obtained immediately to verify the diagnosis, and surgery should be performed soon thereafter. If there is a significant time delay, the fracture–dislocation will be exceedingly difficult to reduce without a formal open reduction (Fig. 61-20). 

Anterior Process of the Calcaneus Fractures

Anterior process fractures will present with pain, swelling, and ecchymosis overlying the anterolateral hindfoot region, along with tenderness to palpation directly over the anterior process fragment. Anterior process of the calcaneus fractures often are misdiagnosed as ankle sprains, hence the designation “sprain-fractures.”20,40,43,64,71 They often result from a forced inversion and plantarflexion injury, which increases tension on the bifurcate ligament, and produces an avulsion fracture.85 The fracture line exits into the calcaneocuboid articulation and typically includes minimal amounts of the articular surface, although varying proportions of the joint surface may be involved. The extensor digitorum brevis muscle may also contribute to the injury pattern. Alternatively, injury to the anterior process region may result from forced abduction of the foot, producing an impaction fracture of the calcaneocuboid articular surface.81 In this instance, the fragment is typically larger with more involvement of the articular surface and may displace posteriorly and superiorly. 

Calcaneal Tuberosity Fractures

Fractures of the calcaneal tuberosity can result in either an open beak-type fracture or an avulsion fracture46,148 (Fig. 61-21). The distinction lies in that the avulsion fracture pulls the entire Achilles tendon from its insertion. Protheroe133 questioned this as he described cases of open beak-type fractures with the entire Achilles tendon avulsed. These two fractures most probably represent a spectrum of injury, resulting most commonly from a violent pull of the gastrocnemius-soleus complex, such as with forced dorsiflexion with a low-energy stumble and fall, producing an avulsed fragment of varying size. 
Figure 61-21
Extra-articular avulsion fracture.
 
A: Lateral and axial radiographs. B: Initial CT scan sections showing nonarticular fracture. C: Further CT scan sections showing nondisplaced fracture into joint. D: Lateral and axial radiographs 1 year post simple cerclage band fixation. E: Displaced avulsion fracture. F: At 5 years post tension band with lag screw fixation.
A: Lateral and axial radiographs. B: Initial CT scan sections showing nonarticular fracture. C: Further CT scan sections showing nondisplaced fracture into joint. D: Lateral and axial radiographs 1 year post simple cerclage band fixation. E: Displaced avulsion fracture. F: At 5 years post tension band with lag screw fixation.
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Figure 61-21
Extra-articular avulsion fracture.
A: Lateral and axial radiographs. B: Initial CT scan sections showing nonarticular fracture. C: Further CT scan sections showing nondisplaced fracture into joint. D: Lateral and axial radiographs 1 year post simple cerclage band fixation. E: Displaced avulsion fracture. F: At 5 years post tension band with lag screw fixation.
A: Lateral and axial radiographs. B: Initial CT scan sections showing nonarticular fracture. C: Further CT scan sections showing nondisplaced fracture into joint. D: Lateral and axial radiographs 1 year post simple cerclage band fixation. E: Displaced avulsion fracture. F: At 5 years post tension band with lag screw fixation.
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Patients with fractures of the calcaneal tuberosity will present with pain and swelling in the posterior hindfoot and may also have weakness with resisted plantarflexion because of the shortened gastrocnemius-soleus complex. Because of the limited soft tissue envelope overlying the tuberosity, displacement of the fragment may endanger the surrounding skin (Fig. 61-22). Thus, care must be taken to assess the overlying skin, as expedient care of the fracture may be necessary to avoid skin slough.62 Surgical repair of calcaneal tuberosity avulsion fractures is indicated when (a) the posterior skin is at risk because of pressure from the displaced tuberosity, (b) the posterior portion of the bone is extremely prominent and will affect shoe wear, (c) the gastrocnemius-soleus complex is incompetent, or, rarely, (d) the avulsion involves the articular surface of the joint. 
Figure 61-22
Calcaneal beak fracture.
 
A: Lateral radiograph showing displacement from pull of Achilles. The patient was discharged from the emergency room in a splint. B: Skin necrosis 1 week later.
A: Lateral radiograph showing displacement from pull of Achilles. The patient was discharged from the emergency room in a splint. B: Skin necrosis 1 week later.
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Figure 61-22
Calcaneal beak fracture.
A: Lateral radiograph showing displacement from pull of Achilles. The patient was discharged from the emergency room in a splint. B: Skin necrosis 1 week later.
A: Lateral radiograph showing displacement from pull of Achilles. The patient was discharged from the emergency room in a splint. B: Skin necrosis 1 week later.
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Calcaneus Fractures Treatment Options

Nonoperative Treatment of Calcaneus Fractures

Indications/Contraindications for Nonoperative Treatment of Calcaneus Fractures

Specific indications for nonoperative treatment include (a) nondisplaced or minimally displaced extra-articular fractures, (b) nondisplaced intra-articular fractures, (c) anterior process fractures with less than 25% involvement of the calcaneocuboid articulation, (d) fractures in patients with severe peripheral vascular disease or insulin-dependent diabetes, (e) fractures in patients with other medical comorbidities prohibiting surgery, (f) fractures in patients who are heavy smokers (two or more packs per day), and (g) elderly patients who are household ambulators. It must be noted that chronologic age is not a contraindication to surgery, as many older patients are healthy and active well into their 70s. Nonoperative treatment may also be necessary when fractures are associated with (a) blistering and massive prolonged edema, (b) large open wounds, or (c) life-threatening injuries. 
Nonoperative treatment is contraindicated for (a) displaced intra-articular fractures involving the posterior facet in an otherwise suitable surgical candidate, (b) anterior process of the calcaneus fractures with more than 25% involvement of the calcaneocuboid articulation, (c) displaced fractures of the calcaneal tuberosity, (d) fracture–dislocations of the calcaneus, and (e) open fractures of the calcaneus (Table 61-1). 
 
Table 61-1
Calcaneus Fractures
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Table 61-1
Calcaneus Fractures
Nonoperative Treatment
Indications Relative Contraindications
Nondisplaced to minimally displaced extra-articular fractures; Nondisplaced intra-articular fractures Displaced intra-articular fractures involving the posterior facet
Anterior process fractures with <25% involvement of calcaneocuboid articulation Anterior process fractures with >25% involvement of calcaneocuboid articulation
Fractures in patients with severe peripheral vascular disease, insulin-dependent diabetes mellitus, medical comorbidities prohibiting surgery, minimally ambulatory elderly patients Displaced fractures of calcaneal tuberosity;
Fracture–dislocations of calcaneus
Open fractures of calcaneus
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Many surgeons still elect to treat calcaneal fractures nonoperatively, because of either a lack of familiarity with operative techniques or fear of potential operative complications.102;132 Nonoperative treatment of a displaced intra-articular fracture involving the posterior facet will result in a calcaneal malunion, which must then be treated with salvage options, the results of which appear to be inferior to those of acute operative treatment.134 

Techniques for Nonoperative Treatment of Calcaneus Fractures

Nonoperative treatment of an intra-articular calcaneal fracture consists of a supportive splint to allow dissipation of the initial fracture hematoma, followed by conversion to a prefabricated fracture boot with the ankle locked in neutral flexion to prevent an equinus contracture, and an elastic compression stocking-to-minimize dependent edema. Early subtalar and ankle joint range-of-motion exercises are initiated, and non–weight-bearing restrictions are maintained for approximately 10 to 12 weeks, until radiographic union is confirmed. 
Most anterior process of the calcaneus fractures are nondisplaced or minimally displaced, and are inherently stable injuries. Nonoperative treatment in this instance consists of fracture boot and stocking immobilization with immediate weight bearing in the boot, and early ankle and subtalar range-of-motion exercises. The fracture should be radiographically healed in 6 weeks. 

Outcomes of Nonoperative Treatment of Calcaneus Fractures

Nonoperative management of a truly nondisplaced fracture (as confirmed on CT scan) generally yields good results. Because the articular surface and overall morphology of the calcaneus is preserved, overall limb function should remain near normal. Patients can generally expect a return to near full activity, provided that subtalar range of motion and stabilizing strength is regained. 
Outcomes of Nonoperative Versus Operative Management of Calcaneus Fractures.
Crosby and Fitzgibbons37 reviewed their results of nonoperative management of calcaneal fractures using a CT classification based on the fracture pattern involving the posterior facet. Small or nondisplaced fractures were classified as type I fractures, displaced fractures as type II, and comminuted fractures as type III fractures. In their series, there were 13 type I, 10 type II, and 7 type III fractures. They reported good results with closed treatment in all type I fractures, but poor results in most type II and type III fractures, and suggested operative treatment was indicated for these fractures. 
Kitaoka et al.90 reviewed fractures in 16 patients treated nonoperatively and used gait analysis to evaluate outcome. Most patients in their series exhibited an altered gait pattern, especially on uneven ground, thus confirming that nonoperative management of calcaneus fractures led to at least some persistent functional impairment. 
In recent years, several studies have been published comparing operative to nonoperative treatment.25,26,80,86,99,123,127,177 Jarvholm et al.86 evaluated 20 patients treated operatively over a 12-year period and compared the results to a historical control group treated nonoperatively over the same time period by other surgeons. They concluded that the problems associated with internal fixation did not justify operative treatment; however, several limitations in their study design were apparent: only a few operative procedures were performed each year; the surgeons did not consistently use lag screws and never stabilized the calcaneal body with a plate or staple; intraoperative fluoroscopy was not available; and the authors conceded they were never able to obtain a perfect reduction. This study illustrates many of the inherent flaws seen in the published literature on calcaneal fractures and thus prohibits the reader from reaching meaningful conclusions. 
Parmar et al.127 compared 31 displaced fractures treated nonoperatively to 25 treated operatively. They used their own classification and fixed fractures with K-wires through a lateral Kocher approach. No attempt was made to reduce the calcaneal tuberosity, and they encountered difficulty in evaluating the postoperative CT scans. Using their own scoring system, they found no difference in clinical outcome between the two groups. The limitations of this study include poor operative fixation techniques and lack of assessment of the postoperative reduction by scans. 
O’Farrell et al.123 treated 12 patients operatively and 12 patients nonoperatively. CT was used; however, the fractures were not classified. In those treated operatively, a Kocher incision was used with lag screw and plate fixation. Postoperative CT evaluation was completed to compare the final overall fracture alignment. Clinical outcome was based on walking distance, subtalar motion, return to work, and shoe size. They concluded that operative treatment was superior, but their limited patient population precluded statistical significance. 
Leung et al.99 compared 44 patients treated operatively with 19 treated nonoperatively in a nonrandomized, retrospective study with an average follow-up of 3 years. Fractures were classified according to the Crosby and Fitzgibbons classification. They used an extensile lateral approach, and the reduction was held with lag screws and plate fixation. At an average of 3-year follow-up, they reported significantly better results in the surgical group with respect to pain, activity, range of motion, return to work, and hindfoot swelling. 
Crosby and Fitzgibbons37 first reported on the results of nonoperative treatment of intra-articular calcaneal fractures in 1990. Because of the poor outcomes with the displaced and comminuted fractures, the authors began treating displaced (type II) fractures.37,38 Results of their operative cases were then compared with their nonoperative cases using the same outcomes assessment instrument. They found superior results in those fractures that were treated operatively; the difference was highly statistically significant. As a result, they recommended operative intervention for displaced fractures. 
Thordarson and Kreiger176 performed a randomized, prospective trial comparing operative to nonoperative treatment in 30 patients. Fractures were classified by CT, and only Sanders type II and type III (displaced) fractures were included in their study. Nonoperative treatment consisted of non-weight-bearing and early range-of-motion exercises. Operative treatment was performed by a single surgeon and consisted of an extensile lateral approach with lag screw and plate fixation. Clinical outcome using the AOFAS Ankle and Hindfoot Score111 was completed in all 15 operatively treated fractures and in 11 of 15 nonoperatively treated fractures. The functional results and overall outcome in the operatively treated group were superior to those in the nonoperative group; the differences were statistically significant. Despite small numbers and a relatively short period of follow-up, this study represented the first randomized, prospective trial where many variables were held constant, and this study confirmed that operative intervention could lead to superior results. 
Buckley and Meek25 first reported their matched cohort series of 34 calcaneal fractures in 1992. Seventeen fractures were treated operatively, and 17 were treated nonoperatively. The patients were matched with respect to age, sex, work type, and time to follow-up. They concluded that their best results were in patients with an anatomic reduction of the posterior facet and that, if an anatomic reduction was not possible, there appeared to be no difference between operative and nonoperative treatment. Unfortunately, no classification was performed, such that fractures were not consistently classified. More important, 12 different surgeons participated in surgical treatment of the 17 patients, and all used different techniques. 
The same group of surgeons then evaluated the literature on this topic. Randle et al.140 performed a meta-analysis of articles between 1980 and 1996 dealing with calcaneal fractures. Of the 1,845 articles, 6 compared operative versus nonoperative treatment for displaced calcaneal fractures using the minimum criteria for inclusion in the meta-analysis. A statistical summary of information across the six articles revealed a trend for surgically treated patients to be more likely to return to the same type of work as compared with nonoperatively treated individuals. There was also a trend for nonoperatively treated patients to have a higher risk of experiencing severe foot pain than did operatively treated patients. Unfortunately, none of the other outcomes could be summarized formally across studies using statistical techniques because of variability in reporting across studies. Although the tendency was always for operatively treated patients to have better outcomes (reaching statistical significance in some of the articles), the strength of evidence to recommend operative treatment for displaced intra-articular calcaneal fractures remained weak. 
Because of the controversies in optimal methods of treatment the Canadian Orthopaedic Trauma Society performed a prospective, randomized, multi-center trial and compared operative with nonoperative treatment of displaced intra-articular calcaneal fractures in 424 patients with 471 fractures.26 Two hundred and eighteen patients with 262 fractures were treated nonoperatively; 206 patients with 249 fractures underwent operative treatment through an extensile lateral approach with screw, plate, or wire fixation. Seventy-three percent of patients were followed for a minimum of 2 years, with an average of 3 years. Fractures were classified according to Sanders, and outcomes were evaluated using two separate previously validated assessment tools. Analysis revealed significantly better results in certain fracture groups undergoing operative treatment, including women, younger patients, patients with a lighter workload, patients not receiving Worker’s Compensation, patients with a higher initial Bohler angle (less severe initial injury), and those with an anatomic reduction on postoperative CT evaluation. There was no difference in overall outcome between the operative and nonoperative groups; however, those having nonoperative treatment of their fracture were 5.5 times more likely to require a subtalar arthrodesis for posttraumatic arthritis than those undergoing operative treatment. 
Radnay et al.134 recently reported on a matched cohort study comparing patients who had undergone initial ORIF and subsequently developed post-traumatic arthritis requiring an in situ fusion with patients treated nonoperatively who developed a calcaneal malunion and required a late reconstruction and subtalar arthrodesis. The ORIF group included 36 ft in 34 patients with an average follow-up of 2.7 years. The average interval from ORIF to late subtalar arthrodesis was 22 months, and 33 of 36 arthrodeses (91.7%) achieved initial union. The calcaneal malunion group included 45 ft in 40 patients with an average follow-up of 5.3 years.31 The average interval from fracture to late reconstruction was 16.4 months, and 37 of 40 arthrodeses (92.5%) achieved initial union. There was a statistical trend toward a lower wound complication rate and significantly higher outcome scores in the ORIF group. This study suggested that the early operative restoration of calcaneal height, length, and overall shape is beneficial to outcome. In the event the patient developed late post-traumatic arthritis, a simple in situ arthrodesis could be performed. 
Outcomes of Treatment of Open Fractures
Folk et al.58 reported wound complications in 13 of 18 open calcaneal fractures that were operatively treated (72%) and calculated that patients with an open fracture were 2.8 times more likely to develop a wound complication than those with a closed fracture. The incidence of these major complications also seems to increase with increasing severity of the soft tissue injury. Siebert et al.161 reviewed the results of 36 open intra-articular fractures treated with internal fixation with an average follow-up of 44 months. Nine of 15 (60%) Gustilo72 type III open fractures developed osteomyelitis, resulting in five amputations. Aggressive surgical treatment of the soft tissue envelope and nonoperative management of the open fracture were recommended. 
Heier et al.78 reported on the results of 43 open fractures in 42 patients managed according to a standard treatment protocol of immediate intravenous antibiotics, aggressive surgical debridement of the wound, and provisional limb stabilization. There were many injuries that defied classification because of the irregular shape and size of the wound. Definitive soft tissue coverage was completed at an average of 10.6 days; final fracture stabilization was delayed until the wound was clean and soft tissue swelling had dissipated. All Gustilo type I open fractures, and Gustilo type II open fractures with a medial wound, were treated with ORIF and a lateral incision after debridement and when tissue edema had resolved. Gustilo type II fractures with lateral, posterior, or plantar wounds and Gustilo type IIIA fractures had limited or no internal fixation. All Gustilo type IIIB open fractures required vascularized free tissue transfer as soon as possible. The overall infection rate was 37%, and osteomyelitis developed in 19%, including 7 of 26 (27%) type III open fractures. All six amputations occurred in patients with open type IIIB fractures. The authors concluded that the degree of soft tissue injury was the most important variable in predicting outcome; thus, all open type I and those open type II fractures with a medial wound could be treated by delayed ORIF once the soft tissues were suitable for surgery. They recommended either external fixation or limited percutaneous fixation for those open type II injuries with nonmedial wounds and all open type IIIA wounds and delayed or late reconstruction for all open type IIIB wounds and for fractures caused by penetrating trauma. 
Aldridge et al.4 reviewed the results of 19 open calcaneal fractures treated by a similar standard protocol at an average follow-up of 26.2 months. Definitive fracture stabilization was completed through a lateral approach, regardless of wound location, at an average of 7 days following injury, at which point soft tissue swelling had adequately dissipated. Two of 19 patients (10.5%) developed a deep infection and subsequent osteomyelitis: One open type II fracture and one open type IIIC fracture, the latter being the only one that went on to amputation. Their results confirmed that open type I fractures had a predictably good outcome with respect to soft tissue infection or osteomyelitis, whereas the open type II and type III fractures were associated with a less predictable outcome, although the overall complication rate was considerably lower than most reported series to date. 
Berry et al.13 reviewed the results of 30 open fractures in 29 patients managed with a standard open fracture protocol and various methods of fracture treatment. There were 2 Sanders type II, 6 type III, and 6 type IV fractures. There were 5 Gustilo type I fractures, 12 type II fractures, and 13 type III fractures (9 IIIA, 2 IIIB, and 2 IIIC injuries). Most of the open wounds occurred along the medial foot with two posterior injuries and three plantar wounds. There were no lateral open wounds. Two patients with Gustilo type IIIC injuries underwent a below knee amputation within the first 24 hours postinjury because of massive crush injuries and dysvascular feet. Only five fractures underwent acute ORIF. Functional outcome was evaluated using validated assessment tools. Although the authors reported only one superficial infection and no cases of deep infection or osteomyelitis, most patients had only fair to poor functional results. Those with plantar wounds had significantly worse functional outcomes relative to those with medial wounds. They concluded that aggressive debridement of open wounds with provisional stabilization of the limb was critical in limb salvage, and based on their five cases, that delayed ORIF was a safe treatment option. 
In Lawrence and Grau’s series of 48 open fractures treated over a 7-year period,95 more than 80% of the wounds were medial injuries, with 23% of these associated with a significant neurovascular deficit. Five patients required a free tissue transfer, whereas two patients underwent below-the-knee amputations as the primary treatment. The authors stressed the need for soft tissue management and delay of definitive internal fixation. 
In contrast, Benirschke and Kramer11 reviewed the results of 39 open calcaneal fractures in 38 patients treated by open reduction and rigid internal fixation through an extensile lateral approach as part of a large series of calcaneal fractures. Their series included 19 open Gustilo type IIIA and 3 open Gustilo type IIIB fractures. Although wound location data were not included, they reported only a 7.7% “serious” wound complication rate, and none required amputation. They concluded that patient noncompliance was the single biggest issue precluding wound healing. 

Operative Treatment of Calcaneus Fractures

Indications/Contraindications

Operative treatment is primarily indicated for (a) displaced intra-articular fractures involving the posterior facet, (b) anterior process of the calcaneus fractures with more than 25% involvement of the calcaneocuboid articulation, (c) displaced fractures of the calcaneal tuberosity, (d) fracture–dislocations of the calcaneus, and (e) selected open fractures of the calcaneus. Basic fracture patterns can be delineated with plain radiographs. A decision can then be made regarding ancillary tests, most commonly CT scans. Surgery should be performed within the initial 3 weeks of injury prior to early consolidation of the fracture. Surgery should not be attempted, however, until swelling in the foot and ankle has adequately dissipated, as indicated by a positive wrinkle test.152 The test is performed by direct palpation and visual assessment of the lateral calcaneal skin with dorsiflexion and eversion of the involved foot. The test is positive if skin wrinkling is seen and no pitting edema is evident, indicating that operative intervention may be safely undertaken (Fig. 61-23). 
Figure 61-23
Wrinkle sign.
 
Note the wrinkling of the skin throughout (open arrows), as well as the visualization of the subluxated peroneal tendons (black arrows) and lateral edge of calcaneal heel pad (white arrows).
Note the wrinkling of the skin throughout (open arrows), as well as the visualization of the subluxated peroneal tendons (black arrows) and lateral edge of calcaneal heel pad (white arrows).
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Figure 61-23
Wrinkle sign.
Note the wrinkling of the skin throughout (open arrows), as well as the visualization of the subluxated peroneal tendons (black arrows) and lateral edge of calcaneal heel pad (white arrows).
Note the wrinkling of the skin throughout (open arrows), as well as the visualization of the subluxated peroneal tendons (black arrows) and lateral edge of calcaneal heel pad (white arrows).
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A variety of methods may be used to reduce swelling of the affected extremity. If the patient is seen initially in the emergency department, immediate elevation in combination with a Jones-type compression dressing with a posterior splint may be used, with or without a compressive pneumatic foot pump.175 In the event of an isolated injury, the patient may be discharged from the hospital and converted to an elastic compression stocking and fracture boot locked in neutral flexion several days later. CT scans and plain radiographs may be reviewed with the patient, and a management plan outlined at that time. Full resolution of soft tissue edema may require up to 21 days. We prefer to proceed with surgical intervention within 2 weeks of injury, although surgery may be safely performed up to 3 weeks from injury. Beyond this interval, early consolidation of the fracture occurs, and the fragments become increasingly difficult to separate and reduce. Furthermore, at the time of attempted reduction, the articular cartilage may be left behind, completely delaminating from the underlying subchondral bone, leaving a facet fragment without any accompanying cartilage. 

Percutaneous and Minimally Invasive Fixation

Indications for percutaneous or minimally invasive fixation include: (a) Sanders 2C tongue-type fractures in which the entire posterior facet is attached to the tongue fragment; (b) displaced calcaneal tuberosity or beak fractures; (c) emergent reduction and temporary stabilization of fractures with severe or impending soft tissue compromise from displaced fracture fragments; (d) fractures in patients with relative contraindications to open surgery, such as heavy smokers or patients requiring chronic anticoagulation. In these instances, an initial closed or percutaneous reduction and temporary stabilization with K-wires may be converted to a formal open procedure for definitive stabilization once the soft tissue envelope has sufficiently recovered. Alternatively, percutaneous fixation may be used as definitive treatment, in which small incisions are used for the placement of Schanz pins and small periosteal elevators in assisting with the reduction, followed by multiple small-fragment screws axially and laterally (Fig. 61-24). 
Figure 61-24
Percutaneous fixation for Sanders 2B split tongue–type fracture.
 
A: Lateral radiograph demonstrating restoration of calcaneal height and crucial angle of Gissane. B: Broden view demonstrating anatomic reduction of posterior facet (black arrow). C: Axial view showing residual shortening and varus malalignment of tuberosity (black arrow).
A: Lateral radiograph demonstrating restoration of calcaneal height and crucial angle of Gissane. B: Broden view demonstrating anatomic reduction of posterior facet (black arrow). C: Axial view showing residual shortening and varus malalignment of tuberosity (black arrow).
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Figure 61-24
Percutaneous fixation for Sanders 2B split tongue–type fracture.
A: Lateral radiograph demonstrating restoration of calcaneal height and crucial angle of Gissane. B: Broden view demonstrating anatomic reduction of posterior facet (black arrow). C: Axial view showing residual shortening and varus malalignment of tuberosity (black arrow).
A: Lateral radiograph demonstrating restoration of calcaneal height and crucial angle of Gissane. B: Broden view demonstrating anatomic reduction of posterior facet (black arrow). C: Axial view showing residual shortening and varus malalignment of tuberosity (black arrow).
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Preoperative Planning.
As with any surgical procedure, preoperative planning is essential in promoting a successful patient outcome. Consideration of these factors ensures that the necessary equipment is available at the time of the procedure. Preoperative planning for surgical management of a calcaneal fracture includes the proper operating table, patient position, fluoroscopy location, tourniquet, surgical equipment, and surgical implants (Table 61-2
Table 61-2
Percutaneous/Minimally Invasive Fixation of Calcaneus Fractures
Preoperative Planning Checklist
  •  
    OR table: Radiolucent or standard table with radiolucent diving board attachment
  •  
    Position/positioning aids: Prone or lateral decubitus on beanbag
  •  
    Fluoroscopy location: Perpendicular to table; opposite the surgeon
  •  
    Equipment: Standard C-arm; cordless drill; Kirschner wires; Schanz pins; periosteal elevators
  •  
    Tourniquet (sterile/nonsterile): Nonsterile
  •  
    Implants: Small-fragment set; large (6.5–8.0 mm) cannulated screw set
X
Positioning for Minimally Invasive Fixation of Calcaneus Fractures.
The patient is placed in the prone position on a radiolucent operating room table; alternatively a standard table with a radiolucent “diving board” attachment may be used. In this position, external rotation of the hip will create the lateral position of the leg, whereas internal rotation will permit access to the medial surface if needed. A nonsterile thigh tourniquet is placed, the limb is exsanguinated following limb preparation, and the tourniquet is inflated. A large sterile bolster is placed under the foot, thereby flexing the knee and facilitating intra-operative fluoroscopy. The C-arm is positioned perpendicular to the operating table and opposite the involved limb. 
Alternatively, the patient may be placed in the lateral decubitus position on a beanbag. The lower extremities are positioned in a scissor-like configuration in which the nonoperative “down” limb lies straight, without the knee bent, and the operative “up” limb is bent at the knee such that the heel is positioned toward the distal, posterior corner of the operating room table. Protective padding is placed beneath the contralateral limb to protect the peroneal nerve, and a “platform” is created with foam padding or blankets to elevate the operative limb (Fig. 61-25 and Table 61-3). 
Figure 61-25
Positioning for lateral approach.
 
A: Well leg in straight knee position (white arrow) with injured side on foam platform. B: External rotation allows Broden view. C: Internal rotation allows a clinical assessment of the tuberosity to determine varus/valgus.
A: Well leg in straight knee position (white arrow) with injured side on foam platform. B: External rotation allows Broden view. C: Internal rotation allows a clinical assessment of the tuberosity to determine varus/valgus.
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Figure 61-25
Positioning for lateral approach.
A: Well leg in straight knee position (white arrow) with injured side on foam platform. B: External rotation allows Broden view. C: Internal rotation allows a clinical assessment of the tuberosity to determine varus/valgus.
A: Well leg in straight knee position (white arrow) with injured side on foam platform. B: External rotation allows Broden view. C: Internal rotation allows a clinical assessment of the tuberosity to determine varus/valgus.
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Table 61-3
Percutaneous/Minimally Invasive Fixation of (Extra-Articular) Tongue-Type Calcaneus Fractures
Surgical Steps
  •  
    Place 2 parallel terminally threaded guidepins into tongue fragment
  •  
    Perform Essex-Lopresti reduction maneuver
  •  
    Advance one guidepin across anterior process toward plantar corner of calcaneocuboid joint; confirm guidepin placement on fluoroscopy; place large cannulated screw over guidepin
  •  
    Exchange other (bent) guidepin for new pin; advance parallel to first guidepin; place second large cannulated screw
  •  
    Use periosteal elevator through lateral stab incision for assistance with reduction if necessary
  •  
    Use large pelvic clamp between sustentaculum and lateral incision for widening between sustentaculum and posterior facet if necessary
  •  
    Add small guidepin from sustentaculum to body of calcaneus; place small cannulated screw
  •  
    Alternatively use cortical lag screws as definitive fixation
X
Surgical Approach(es) for Minimally Invasive Fixation of Calcaneus Fractures.
Unfortunately it is not that simple, in that there is no standard approach for minimally invasive fixation of calcaneus fractures. These techniques remain somewhat in evolution. 
Technique for Minimally Invasive Fixation of Calcaneus Fractures.
Sanders 2C tongue-type fractures and displaced calcaneal tuberosity or beak fractures are particularly amenable to percutaneous reduction and fixation. Under fluoroscopic guidance in the lateral view, two large terminally threaded guide pins from a large cannulated screw set are inserted percutaneously into the medial and lateral borders of the Achilles tendon at the superior aspect of the posterior calcaneal tuberosity. The pins are directed to exit the fracture just below the inferior margin of the anterior portion of the displaced posterior facet, but are not driven beyond the facet. A posteroanterior fluoroscopic image confirms the wires to be parallel with the axis of the tuberosity and within bone. Once the wires are in proper position, the reduction maneuver is performed by using one of the wires as a reduction tool (Fig. 61-26). 
Figure 61-26
Percutaneous Essex-Lopresti maneuver.
 
A: With patient prone, leverage of heavy K-wires toward the ceiling (arrow) will cause (B) disimpaction and elevation of fragment (arrow).
A: With patient prone, leverage of heavy K-wires toward the ceiling (arrow) will cause (B) disimpaction and elevation of fragment (arrow).
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Figure 61-26
Percutaneous Essex-Lopresti maneuver.
A: With patient prone, leverage of heavy K-wires toward the ceiling (arrow) will cause (B) disimpaction and elevation of fragment (arrow).
A: With patient prone, leverage of heavy K-wires toward the ceiling (arrow) will cause (B) disimpaction and elevation of fragment (arrow).
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The reduction is performed according to the method of Tornetta et al.179,180 The first step is to disimpact the fracture by lifting up on one of the pins and simultaneously plantarflexing the foot (Figs. 61-27A and B). Reduction of the tongue fragment is confirmed fluoroscopically while the foot is held in plantarflexion. If this is successful, the second pin is advanced across the anterior process, stopping just short of the plantar corner of the calcaneocuboid joint (Figs. 61-27C and D). A Broden view is obtained (mortise view of the ankle) and reduction of the articular surface is assessed under fluoroscopy. Placement of the guidepin is confirmed with lateral, axial, and anteroposterior views of the foot. Definitive fixation is achieved with a large (6.5 to 8.0 mm) cannulated lag screw that is inserted over the guidewire through small stab incisions placed around the guidepins. Because the original pin is now bent from the reduction, it is exchanged for a new wire and measured, and another cannulated screw is placed into the calcaneus (Fig. 61-27). 
Figure 61-27
Essex-Lopresti technique as modified by P.
 
Tornetta, MD. Once guidepins are correctly positioned, they are exchanged for 6.5 to 8.0-mm cannulated cancellous lag screws.
Tornetta, MD. Once guidepins are correctly positioned, they are exchanged for 6.5 to 8.0-mm cannulated cancellous lag screws.
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Figure 61-27
Essex-Lopresti technique as modified by P.
Tornetta, MD. Once guidepins are correctly positioned, they are exchanged for 6.5 to 8.0-mm cannulated cancellous lag screws.
Tornetta, MD. Once guidepins are correctly positioned, they are exchanged for 6.5 to 8.0-mm cannulated cancellous lag screws.
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Alternatively, 3.5-mm cortical lag screws may be used as definitive fixation. Two or three parallel screws are placed perpendicular to the tongue fracture line, exiting the plantar cortex. An additional cortical lag screw may be placed from lateral to medial, well beneath the posterior facet articular surface and into the sustentaculum for additional stability (Fig. 61-28). 
A: Lateral radiograph. B: Broden view.
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Figure 61-28
Essex-Lopresti maneuver and percutaneous fixation with small-fragment cortical lag screws.
A: Lateral radiograph. B: Broden view.
A: Lateral radiograph. B: Broden view.
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A sinus tarsi incision may additionally be utilized for direct visualization of the posterior facet articular surface. In this instance, percutaneous screws are placed more plantarly from calcaneal tuberosity into the anterior process, and beneath the displaced posterior facet fragments. A small mini-fragment buttress plate may be placed from the articular rim of the posterior facet to the anterior process region to buttress the articular reduction and help to maintain the crucial angle of Gissane122,159 (Fig. 61-29). 
Figure 61-29
Sinus Tarsi Approach/Percutaneous Fixation.
 
A: Sinus tarsi approach. B: Lateral view demonstrating percutaneous plate fixation.
 
Images courtesy of Steven D. Steinlauf, MD.
A: Sinus tarsi approach. B: Lateral view demonstrating percutaneous plate fixation.
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Figure 61-29
Sinus Tarsi Approach/Percutaneous Fixation.
A: Sinus tarsi approach. B: Lateral view demonstrating percutaneous plate fixation.
Images courtesy of Steven D. Steinlauf, MD.
A: Sinus tarsi approach. B: Lateral view demonstrating percutaneous plate fixation.
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Postoperative Care after Minimally Invasive Fixation of Calcaneus Fractures.
The stab incisions are closed with 3-0 monofilament sutures and a bulky Jones dressing with Weber splint is placed. The patient is converted back to a compression stocking and fracture boot at 2 weeks postoperatively, and ankle and subtalar range-of-motion exercises are begun. Non–weight-bearing restrictions are maintained for 10 to 12 weeks postoperatively, at which point the fracture should be radiographically healed. 
Potential Pitfalls and Preventative Measures for Minimally Invasive Fixation of Calcaneus Fractures (Table 61-4)
 
Table 61-4
(Extra-Articular) Tongue-Type Calcaneus Fractures
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Table 61-4
(Extra-Articular) Tongue-Type Calcaneus Fractures
Potential Pitfalls and Preventions
Pitfall Preventions
Tongue fragment won’t disimpact with guidepins and Essex-Lopresti maneuver Ensure that guidepins are not advanced beyond anterior-inferior edge of posterior facet
Use small periosteal elevator through lateral stab incision to assist in reduction of tongue fragment
Tongue fragment will reduce but won’t hold Place 1.6 mm K-wires from tongue fragment across subtalar joint into talus to temporarily hold fragment elevated
Widening between posterior facet and sustentaculum Use large pelvic clamp between sustentaculum and lateral fragment to narrow gap; stabilize with small cortical (lag) or cannulated screw
X
If the fragment does not disimpact, a 5-mm lateral incision should be made directly over the anterior-inferior edge of the fragment, as verified on radiography. This will invariably be at the level of the peroneal tendons and sural nerve, so care must be taken to only incise the skin and protect the soft tissues by spreading with a clamp. A small periosteal elevator is then inserted under fluoroscopic control, and the distal corner of the fragment is pried free, disimpacting the tongue fragment. If the reduction is obtained but cannot be held, 1.6-mm K-wires may be inserted into the fragment and across the subtalar joint to maintain reduction while the axial screws are placed. 
Finally, if reduction is obtained in the sagittal plane but widening between the sustentaculum and the joint fragment exists in the coronal plane, a large pelvic reduction tong is placed through the incision on the lateral side, and on the sustentaculum on the medial side, to compress and reduce the fragments. This may be held with a 1.6-mm wire and followed with a small-fragment cannulated screw, inserted from the medial side to lag the lateral fragment, thereby narrowing the joint. 
Outcomes for Minimally Invasive Fixation of Calcaneus Fractures.
Tongue-type fractures are particularly amenable to minimally invasive approaches. Fixation techniques for tongue-type fractures using a percutaneous “nail” were first advocated by Westhues.189 The technique was modified by Gissane,68 who developed the Gissane Spike for this procedure. It was Essex-Lopresti, however, who described the technique in detail and popularized the maneuver specifically for tongue-type fractures.54 Over time, this technique was used for all types of calcaneal fractures with poor results, and thus fell into disfavor. Tornetta179 reviewed the original technique, reporting on the results of 26 patients with Sanders type IIC (extra-articular tongue-type) fractures using the Essex-Lopresti maneuver with a modification of fixation (Fig. 61-27). Steinmann pins were initially used for definitive fixation, but these were changed to 6.5-mm cannulated screws later in the series. Three patients were considered intraoperative failures, in that the technique was abandoned in these patients in favor of traditional ORIF. The reduction maneuver was successful in 88%. There were 86% good or excellent results based on the Maryland Foot Score at an average follow-up of 2.9 years. 
Sangeorzan and Ringler157 reviewed the results of 36 tongue-type calcaneal fractures managed with a minimally invasive reduction technique and small-fragment fixation with an average follow-up of 25.5 months. The operative technique involved small (less than 1 cm) incisions, which were used for the introduction of Schantz pins and small elevators for the reduction. The fracture fragments were aligned with the Essex-Lopresti reduction technique. All reductions were performed under fluoroscopic guidance and were stabilized with small-fragment screw fixation. Two screws were introduced in an axial direction, and any subsequent screws were introduced from the lateral surface to secure the sustentaculum. Postoperatively, patients were placed in a removable splint and range of motion was begun postoperatively within 1 to 2 days. Weight bearing was initiated after 2 to 3 months. There were no infections and no cases of lost fracture reduction, and only one patient went on to require a subtalar arthrodesis. They concluded that their technique lowered the incidence of postoperative risks and reduced the length of hospital stay compared to historical controls. 
Rammelt et al.135137 noted that percutaneous reduction methods play an important role in the management of calcaneal fractures with severe soft tissue compromise, particularly open fractures. Percutaneous reduction by pin leverage (Westhues or Essex-Lopresti maneuver) followed by minimally invasive screw fixation was a treatment option that yielded good-to-excellent results in tongue-type fractures with posterior facet displacement as a whole (Sanders type IIC). The authors noted that the method could also be applied to selected Sanders type IIA or IIB fractures if the joint reduction was controlled arthroscopically. 
DeWall, et al.45 compared initial results of a group of displaced intra-articular calcaneal fractures treated by percutaneous reduction and screw fixation with a control group of fractures treated using a traditional open technique with plate and screw fixation. They reported significantly lower wound complication and infection rates in the percutaneous group, and comparable extra-articular reduction between the two groups. Unfortunately, postoperative CT scans were not included, so the intra-articular reduction could not be compared between the two groups. 
Forgon59 described a method of three-point skeletal traction applied to the tuberosity, talus, and cuboid, using ligamentotaxis to manipulate the main fragments. The depressed posterior facet is elevated percutaneously with a K-wire introduced laterally. The reduction is confirmed on fluoroscopy and the fragments are fixed with percutaneously placed lag screws. Other authors have described percutaneous or mini-open reduction with use of small wire circular external fixators.53,108 The use of temporary uniplanar, unilateral external fixation has also been described.103 The early results of these minimally invasive approaches are comparable to traditional open methods. 
In an effort to reduce the risk of problems with wound healing, Weber et al.188 presented a technique that combined open reduction and fixation of the joint fragments and the anterior process, with percutaneous reduction and screw fixation of the tuberosity. A group of 24 patients with unilateral isolated closed Sanders type II and III fractures was treated using this technique and, compared with a similar group of 26 patients, managed by the extended approach and lateral plating. The operation was significantly quicker (p < 0.001) in the first group, but more minor secondary procedures and removal of screws were necessary. There were no wound complications in this group, whereas four minor complications occurred in the second group. According to the authors, the ultimate functional results were equivalent in both groups. Unfortunately, despite the fact that the authors thought postoperative CT scans were not needed, since these were not obtained, the accuracy and maintenance of the joint reduction using this minimal technique could not be assessed, limiting the usefulness of this report. 
The use of the limited sinus tarsi approach has gained popularity in recent years, which allows direct visualization of the posterior facet. This may expand the indications to include simple intra-articular and joint-depression patterns.122,159 Nosewicz, et al.122 reported on a series of Sanders II and III fractures treated through a sinus tarsi approach with lateral mini-fragment plate and percutaneous screw fixation. CT scans were obtained immediately following surgery and at 1 year postoperatively. They reported a good or excellent reduction of the posterior facet and calcaneocuboid joint in 64% of patients immediately following surgery, and in 68% at 1 year postoperatively; however, 50% percent of their patients required implant removal at 1 year postoperatively. 
Some authors have expanded the use of percutaneous reduction by traction, leverage, and compression with subsequent K-wire or screw fixation for all types of calcaneal fractures.135,191 Stulik et al.173 reported on the treatment of 287 Sanders type II, III, and IV fractures using minimally invasive techniques. A four-step procedure using a traction bow, a percutaneous joint reduction using a plantar placed punch, lateral heel compression, and percutaneous pinning was performed. A near anatomic reduction was possible in 73.9% of fractures, with a 4.5% loss of reduction, and a 7% superficial pin tract infection. Using the Creighton-Nebraska score, clinical outcomes included 29 excellent, 98 good, 26 fair, and 23 poor results. They noted that tongue-type fractures had better results than joint-depression fractures, but Sanders type III tongue fractures were very difficult to reduce using their methods. Results also worsened with an increased number of fracture fragments, as previously described by Sanders et al.152,154 Interestingly, at a minimum of 2-year follow-up, joint narrowing and subchondral sclerosis were seen in 85.7% of cases, possibly indicating the arthritic demise of a joint that was not anatomically reduced but mobile. Nonetheless, the authors stated that 72% of patients returned to their preinjury work and that this technique would work well in most cases. 
Ziran and Bosch191 described their results in 28 comminuted, Sanders type III/IV calcaneus fractures treated with closed reduction and percutaneous pinning. With the help of a traction bow and Steinmann pin, reduction of the body was performed. There was no attempt made to reduce the subtalar joint. After fixation, patients were splinted and then braced with a posterior relief ankle–foot orthosis that allowed ankle motion. Pin care was performed 3 times a day. Patients remained nonweight bearing for 12 weeks, at which point the pins were taken out in the office and weight bearing was initiated. Twenty-five fractures in 21 patients were available for review with an average follow-up of 1 year. Subtalar motion was less than 10 degrees in all the cases. Twelve patients reported minimal to no pain with full activity. These patients used normal shoes and had no limp. Seven patients had moderate discomfort with full activity: Two had peroneal tendonitis from the lateral wall of the calcaneus. Two patients had severe pain with activity and had difficulties with shoe wear. They both had a shortened hindfoot with 15 degrees of varus of their calcaneus. The authors concluded that in all their cases an anatomic, open reduction would have been the better technique. 
A major concern surrounding the application of minimally invasive approaches is the potential for incomplete or malreduction of the posterior facet. Inadequate reduction and/or loss of reduction of the articular fragments may occur in a significant number of cases. Rammelt et al.135,137 have successfully used subtalar arthroscopy to assist in judging the quality of articular reduction. They noted, however, that a uniform application of percutaneous reduction and fixation methods to all types of calcaneal fractures carried a considerable risk of inadequate joint reconstruction and redislocation. Intraoperative CT scanning may improve the execution of minimally invasive techniques but is not readily available in most settings.8,89,144 Finally, prolonged transfixation of the subtalar and calcaneocuboid joints may be needed to maintain reduction but should be avoided as significant subtalar stiffness may result.54 In conclusion, minimally invasive and/or percutaneous techniques should be reserved for relatively simple tongue-type fracture patterns. Before attempting these technically demanding approaches, surgeons should be thoroughly familiar with the pathoanatomy of intra-articular calcaneal fractures and have mastery of traditional open techniques. 

ORIF Through an Extensile Lateral Approach for Joint-Depression Fractures

Preoperative Planning for ORIF Through an Extensile Lateral Approach for Joint-Depression Fractures.
The plain radiographs and CT scan should be thoroughly reviewed in an attempt to gain a preliminary understanding of the “personality” of the fracture pattern, including: The number of articular fragments and extent of articular fragment displacement; extent of overall loss of calcaneal height and length; extent of comminution through the anterior process; and fracture extension into and/or articular stepoff in the calcaneocuboid joint. This allows the surgeon to anticipate certain technical maneuvers to facilitate fracture reduction, as well as the need for additional implants specific to the fracture pattern. This preparation ultimately saves tourniquet time, which may decrease the wound complication rate (Table 61-5). 
 
Table 61-5
ORIF of Intra-Articular Calcaneus Fractures
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Table 61-5
ORIF of Intra-Articular Calcaneus Fractures
Preoperative Planning Checklist
  •  
    OR table: Radiolucent or standard table with radiolucent diving board attachment
  •  
    Position/positioning aids: Lateral decubitus on beanbag
  •  
    Fluoroscopy location: Perpendicular to table; opposite the surgeon
  •  
    Equipment: Standard C-arm; cordless drill; Kirschner wires; Schanz pins; periosteal elevators; pituitary rongeurs; laminar spreaders
  •  
    Tourniquet (sterile/nonsterile): Nonsterile
  •  
    Implants: Small-fragment set; anatomic calcaneal plates (nonlocking vs. locking); bioresorbable smooth pins; drain
X
Positioning for ORIF Through an Extensile Lateral Approach for Joint-Depression Fractures.
For isolated fractures, the patient is placed in the lateral decubitus position on a beanbag. The lower extremities are positioned in a scissor-like configuration whereby the nonoperative “down” limb lies straight, without the knee bent, and the operative “up” limb is bent at the knee such that the heel is positioned toward the distal, posterior corner of the operating room table. This allows the surgeon to easily approach the fracture from the posterior corner of the table, while permitting intraoperative fluoroscopy from the opposite side of the table without interference of the opposite limb. Protective padding is placed beneath the contralateral limb to protect the peroneal nerve, a pillow is placed between the legs, and a “platform” is created with foam padding or blankets to elevate the operative limb (Fig. 61-25). 
A pneumatic thigh tourniquet is used in all cases, and the limb is exsanguinated with an Esmarch bandage to provide a dry operative field. Every effort should be made to complete the procedure within a maximum tourniquet time of 2½ hours. If the procedure extends beyond that time, the tourniquet must be released, and the remainder of the procedure performed without it. All patients should receive preoperative prophylactic antibiotics prior to surgery, and an additional dose of antibiotics is administered following deflation of the tourniquet. 
Surgical Approach(es) for ORIF Through an Extensile Lateral Approach for Joint-Depression Fractures.
The lateral extensile incision is then marked (Fig. 61-30A). The incision starts approximately 2 cm above the tip of the lateral malleolus, just lateral to the Achilles tendon. This line is continued vertically toward the plantar surface of the heel. It is connected to a line drawn at the junction of the lateral foot and the heel pad—typically when compressing the heel, a crease will appear in this region. Posteriorly, this line connects to the vertical limb; anteriorly, it may be curved up to follow the skin creases, ideally centering over the middle of the calcaneocuboid joint articulation, or carried straight to the base of the fifth metatarsal. Whereas the two drawn lines form a right angle, this is replaced with a gentle curve, primarily to avoid apical tip necrosis. The skin of the lateral heel is supplied primarily by the lateral calcaneal artery, which runs with the sural nerve, and at the level of the distal fibula, sits midway between the fibula and the Achilles.19 Because the vertical limb of the incision is made immediately lateral to the Achilles, dissection is posterior and ultimately deep to the lateral calcaneal artery (and sural nerve), which preserves vascularity to the full-thickness flap (Fig. 61-31). 
Figure 61-30
 
Extensile lateral approach and exposure (fracture lateral, mortise, and CT scans can be seen in Figs. 61-7, 8, 9, and 11). A: Planned incision. B: No touch full-thickness incision, using no retractors (note open Adson forceps as only means of assistance). C: Insertion of Senn retractor once subperiosteal flap has been developed in corner of incision. D: Flap development, with identification and protection of peroneal tendons (black arrows).
Extensile lateral approach and exposure (fracture lateral, mortise, and CT scans can be seen in Figs. 61-7, 8, 9, and 11). A: Planned incision. B: No touch full-thickness incision, using no retractors (note open Adson forceps as only means of assistance). C: Insertion of Senn retractor once subperiosteal flap has been developed in corner of incision. D: Flap development, with identification and protection of peroneal tendons (black arrows).
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Figure 61-30
Extensile lateral approach and exposure (fracture lateral, mortise, and CT scans can be seen in Figs. 61-7, 8, 9, and 11). A: Planned incision. B: No touch full-thickness incision, using no retractors (note open Adson forceps as only means of assistance). C: Insertion of Senn retractor once subperiosteal flap has been developed in corner of incision. D: Flap development, with identification and protection of peroneal tendons (black arrows).
Extensile lateral approach and exposure (fracture lateral, mortise, and CT scans can be seen in Figs. 61-7, 8, 9, and 11). A: Planned incision. B: No touch full-thickness incision, using no retractors (note open Adson forceps as only means of assistance). C: Insertion of Senn retractor once subperiosteal flap has been developed in corner of incision. D: Flap development, with identification and protection of peroneal tendons (black arrows).
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Figure 61-31
Lateral vascular anatomy.
 
(Redrawn from Borrelli J Jr, Lashgari C. Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop Trauma. 1999;13:73–77, with permission)
(Redrawn from Borrelli J Jr, Lashgari C. Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop Trauma. 1999;13:73–77, with permission)
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Figure 61-31
Lateral vascular anatomy.
(Redrawn from Borrelli J Jr, Lashgari C. Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop Trauma. 1999;13:73–77, with permission)
(Redrawn from Borrelli J Jr, Lashgari C. Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop Trauma. 1999;13:73–77, with permission)
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The limb should be placed on a “bump” of rolled towels beneath the involved ankle for better leverage and access to the heel. The incision is started at the proximal part of the vertical limb, becoming full thickness once the calcaneal tuberosity is reached. The knife should be taken “straight to bone”70,128 at this level, with care taken not to bevel the skin. As the knife rounds the corner, pressure is relaxed and a layered incision is developed along the plantar aspect of the foot. Once the initial incision is made, attention is then turned to the corner of the flap, which is now raised as a subperiosteal, full-thickness flap (Fig. 61-30B). Gentle downward pressure on the scalpel will produce a slight bend in the blade, which allows precise elevation of the periosteum while preventing undue hand fatigue. The surgeon should refrain from using retractors at this stage, as these will separate the skin from the subcutaneous layer. Only once a sizeable flap “(up to 3 cm)” has been raised. (Fig. 61-30C). At this point, the calcaneofibular ligament is encountered and peeled off the calcaneus. The peroneal tendons are seen next. They must be carefully retracted, and both must be visualized or, as one dissects, the tendons will be lacerated (Fig. 61-30D). The tendons are dissected off the peroneal tubercle and then freed from the anterior calcaneus, using a periosteal elevator. This maneuver should expose the entire anterolateral calcaneus. 
Next, 1.6-mm K-wires are strategically inserted to retract the flap using a “no-touch” technique. The peroneal tendons are slightly subluxed (not dislocated!) anterior of the lateral malleolus. A K-wire is then inserted into the fibula to retract them and the proximal flap (Fig. 61-32A). A second K-wire is placed in the talar neck, retracting the midportion of the peroneal tendons and the flap. The distal peroneal tendons are forcibly lifted with an elevator, and a third K-wire is placed in the cuboid, thereby retracting the distal aspect of the tendons and the flap. A fourth K-wire may be placed posteriorly in the talar body, for visualization of the back corner of the posterior facet. A small Bennett retractor can then be placed into the sinus tarsi over the anterolateral corner of the calcaneus to complete the exposure of the entire lateral wall. 
Figure 61-32
Exposure and disimpaction of subtalar joint.
 
A: K-wires are inserted into fibula, subluxing peroneal tendons. B: No-touch technique, completed with three K-wires and Schanz pin in tuberosity. C: Identification and separation of lateral wall. D: Lateral wall. E: Exposure of the articular fracture displaying the pathology associated with the double density sign (black arrow = sustentacular fragment, white arrow = lateral articular fragment). F: Disimpaction of the lateral articular fragment.
A: K-wires are inserted into fibula, subluxing peroneal tendons. B: No-touch technique, completed with three K-wires and Schanz pin in tuberosity. C: Identification and separation of lateral wall. D: Lateral wall. E: Exposure of the articular fracture displaying the pathology associated with the double density sign (black arrow = sustentacular fragment, white arrow = lateral articular fragment). F: Disimpaction of the lateral articular fragment.
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Figure 61-32
Exposure and disimpaction of subtalar joint.
A: K-wires are inserted into fibula, subluxing peroneal tendons. B: No-touch technique, completed with three K-wires and Schanz pin in tuberosity. C: Identification and separation of lateral wall. D: Lateral wall. E: Exposure of the articular fracture displaying the pathology associated with the double density sign (black arrow = sustentacular fragment, white arrow = lateral articular fragment). F: Disimpaction of the lateral articular fragment.
A: K-wires are inserted into fibula, subluxing peroneal tendons. B: No-touch technique, completed with three K-wires and Schanz pin in tuberosity. C: Identification and separation of lateral wall. D: Lateral wall. E: Exposure of the articular fracture displaying the pathology associated with the double density sign (black arrow = sustentacular fragment, white arrow = lateral articular fragment). F: Disimpaction of the lateral articular fragment.
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Technique for ORIF Through an Extensile Lateral Approach for Joint-Depression Fractures (Table 61-6)
 
Table 61-6
ORIF of Intra-Articular Calcaneus Fractures
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Table 61-6
ORIF of Intra-Articular Calcaneus Fractures
Surgical Steps
  •  
    Perform extensile lateral approach to calcaneus
  •  
    Place K-wire retractors in cuboid, talar neck, and fibula
  •  
    Mobilize lateral wall and superolateral articular fragments
  •  
    Mobilize tuberosity through primary medial fracture line
  •  
    Place Schanz pin in tuberosity
  •  
    Reduce superolateral articular fragment to sustentacular fragment
  •  
    Provisionally stabilize with K-wires
  •  
    Reduce anterior process and anterolateral fragment(s) to articular fragments to restore crucial angle of Gissane
  •  
    Provisionally stabilize with K-wires
  •  
    Reduce tuberosity to body of calcaneus; provisionally stabilize with K-wires
  •  
    Replace lateral wall fragment; add bone void filler as needed
  •  
    Apply anatomic calcaneal plate
  •  
    Place cortical or cancellous screws through perimeter holes in plate in box configuration
  •  
    Place cortical lag screws to stabilize articular fragment(s)
  •  
    One screw through plate; one screw outside plate
  •  
    Assess stability of superior peroneal retinaculum
  •  
    Flap closure over deep drain; sutures tied sequentially from ends to apex; skin closure in identical sequence
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Fragment Mobilization
The posterior inferior corner of the calcaneal tuberosity is predrilled, and a short Schantz pin is placed from lateral to medial, as described by Benirschke12 (Fig. 61-32B). Using the Schantz pin, the tuberosity is pulled plantarward and distracted into varus. In fresh fractures, this will disimpact several fracture lines within the lateral wall, making the edge of the fragment easier to see. The lateral wall fragment is then carefully elevated in one piece, using a knife to dissect it free from the impacted joint fragment (Fig. 61-32C). While this lateral wall fragment can be retracted, the authors typically resect the thin fragment, which has no soft tissue attachment and place it in a small container with saline on the back table (Fig. 61-32D). 
The articular fracture is now evaluated. A Freer elevator is placed into the remaining joint and, using irrigation and suction, all clot is removed. Once the fracture is identified, elevation of fragments occurs (Fig. 61-32E). Obviously, this is easier with simpler fractures, but the technique is the same for all types. Importantly, the most plantar edge of the depressed fragment is located. It is carefully cleaned of debris. A small periosteal elevator or Hoke osteotome is used to get completely underneath the fragment. If a substantial amount of the fragment is not under the operator’s control, it will splinter when attempting to disimpact it. Care must be taken to disimpact the fragment gradually, as it can be fairly well incarcerated, and sudden forceful movements will cause it to become a projectile (Fig. 61-32F). Once lifted, it should be examined for chondral damage. In the vast majority of cases, these pieces are large, free osteochondral fragments and can be easily removed and placed in saline on the back table. This will afford an excellent view of the medial sustentacular component and the posterior tuberosity, as well as the primary medial fracture line. 
After any remaining clot is removed from the medial edge of the posterior tuberosity fragment, a broad periosteal elevator is placed into the medial fracture line from the lateral wound, and the posterior tuberosity is disimpacted from the sustentaculum, which restores the height and length of the calcaneus (Fig. 61-33A). Often, this requires force but will restore the medial wall anatomically, unless the wall is severely comminuted. In this case, or if the reduction is unstable, a K-wire is placed from the back of the heel through the posterior tuberosity and into the medial sustentacular component, making sure the wire does not interfere with subsequent joint reduction. While this may be helpful, often the wire will interfere with articular reduction maneuvers and may need to be removed. 
Figure 61-33
Joint reduction maneuvers.
 
A: Posterior tuberosity is disimpacted. B: Articular fragment cleaned of clot and debris. C: Joint reduction with two K-wires. D: Lag screw fixation of joint.
A: Posterior tuberosity is disimpacted. B: Articular fragment cleaned of clot and debris. C: Joint reduction with two K-wires. D: Lag screw fixation of joint.
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Figure 61-33
Joint reduction maneuvers.
A: Posterior tuberosity is disimpacted. B: Articular fragment cleaned of clot and debris. C: Joint reduction with two K-wires. D: Lag screw fixation of joint.
A: Posterior tuberosity is disimpacted. B: Articular fragment cleaned of clot and debris. C: Joint reduction with two K-wires. D: Lag screw fixation of joint.
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Articular Reduction
The articular fragment(s) are now evaluated. They are cleaned of clot and impacted cancellous bone (Fig. 61-33B). If one fragment is present (type II fracture), the lateral fragment is skewered with two 1.6-mm K-wires as handles, brought into wound, reduced, and K-wires advanced across the fracture line. 
If two fragments are present (type III fracture), they are assembled working from medial to lateral. The central fragment is first reduced and provisionally stabilized to the sustentacular fragment using 1.6-mm K-wires, which are then exchanged for 1.5-mm resorbable poly-levoactic acid (PLLA) pins (Linvatec; ConMed, Largo, FL).113 Alternatively, the K-wires may be driven through the medial wall of the calcaneus until the proximal end of the K-wire is flush with the central fragment. Caution must used in this instance to avoid the nearby neurovascular structures. Once this is accomplished, the lateral fragment is then skewered with two K-wires as handles and reduced to the central and sustentacular fragments. 
Although it is impossible to describe every reduction maneuver, it is critical to understand several key points about the reduction in general. The articular fragment should be repositioned such that height, rotation, and varus–valgus alignment are correct. This will not be possible if the inferior portion of the articular fragment bangs into the edge of the posterior tuberosity; therefore, the posterior and inferior path for the fragment must be free of bony obstructions. This may require the surgeon to curette excess bone from the tuberosity, disimpact the tuberosity with excess varus force, or remove a small amount of tuberosity bone that is blocking the reduction with a rongeur. 
The anterior process and anterior main fragments must be carefully evaluated before reducing the posterior facet articular surface. The anterior calcaneus can be in as many as three pieces, with the central fragment pulled up because of its attachment to the interosseous ligament. To reduce the anterior fragments, a laminar spreader is often used to stretch the ligament, thereby allowing the central piece to be more easily repositioned. The surgeon should resist the temptation to cut the ligament as this will destabilize the joint over time. In addition, a transverse fracture line at the crucial angle of Gissane may be present. This has the effect of rotating the medial articular (sustentacular) fragment underneath the anterior main fragment. Before reduction of the articular fragment(s), therefore, the sustentacular fragment must be disimpacted and reduced, or the reduction of the articular fragment(s) of the posterior facet will be to a fragment that is itself malpositioned. These reductions will need to be provisionally held with the use of K-wires, placed in a manner so as not to interfere with the subsequent articular reduction. 
The articular fragment is provisionally reduced and held with 1.6-mm K-wires, and the posterior facet reduction is assessed through “window” visualization (Fig. 61-33C). At this point, the anterior “corner” of the superolateral articular fragment should align with the anterior “corner” of the medial sustentacular fragment. Similarly, after a small Hohmann retractor is placed at the posterior edge of the joint, usually on the back of the talar body, the corners of the two fragments should line up posteriorly as well. Once satisfied with the reduction, at least two K-wires should be placed across the fracture fragments (to prevent rotation of the fragments), and further visual evaluation should be performed to assess the joint reduction, both in the front and in the back. When satisfied, the lateral wall and body should reduce nicely with a valgus manipulation of the Schantz pin. The anterolateral fragment should either fall in place or be manipulated back into position, and held in place with K-wires. The best assessment of this reduction will be to see that the posterior most edge of the anterolateral fragment “clicks” into place with the anteroinferior portion of the articular fragment, thereby restoring the crucial angle of Gissane. At this point, the small remnant of the lateral wall should drop into place anatomically, verifying at least that the lateral column is anatomically reduced. 
Once satisfied with the reduction, the surgeon should obtain intraoperative lateral, Broden, and axial fluoroscopic views. The lateral is the easiest view and is taken first. This should be a true lateral of the talus, to delineate the calcaneus accurately (Fig. 61-34A-B). Next, with the fluoroscope in the same position, the leg is externally rotated 45 degrees and dorsiflexed. A mortise view of the ankle is then obtained, showing clearly the posterior facet in a Broden view (Fig. 61-34C-D). Thereafter, the head of the fluoroscope can be rotated to show both the front and the back portions of the posterior facet. Finally, the foot is externally rotated 90 degrees and maximally dorsiflexed. The fluoroscope is then rotated so that it is directing the beam from plantar to dorsal, at the level of the midfoot, to allow a clear axial view of the calcaneus to be obtained. A 2.7-mm sinuscope may additionally be used without fluid to visualize the joint as well. This is particularly helpful with extremely medial fracture lines (Fig. 61-35). The articular fragments may be repositioned as needed until anatomic reduction of the articular surface is confirmed. 
Figure 61-34
Intraoperative imaging.
 
A–B: Lateral intraoperative fluoroscopic view. C–D: Broden intraoperative view. Note black arrow indicating level of fracture and an anatomic reduction.
A–B: Lateral intraoperative fluoroscopic view. C–D: Broden intraoperative view. Note black arrow indicating level of fracture and an anatomic reduction.
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Figure 61-34
Intraoperative imaging.
A–B: Lateral intraoperative fluoroscopic view. C–D: Broden intraoperative view. Note black arrow indicating level of fracture and an anatomic reduction.
A–B: Lateral intraoperative fluoroscopic view. C–D: Broden intraoperative view. Note black arrow indicating level of fracture and an anatomic reduction.
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Before (A) and after (B) lag screw fixation.
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Figure 61-35
If the articular fracture line is extremely medial, a 2.7-mm sinuscope can be used to visualize the reduction.
Before (A) and after (B) lag screw fixation.
Before (A) and after (B) lag screw fixation.
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Definitive Fixation
Definitive fixation of the posterior facet is achieved by using 2.7- to 3.5-mm cortical lag screws placed from the lateral cortex aiming slightly plantarly, to avoid violating the intra-articular surface, and distally toward the sustentaculum (Fig. 61-33D). Once this is completed, the joint should be reassessed both visually and fluoroscopically (Fig. 61-34). 
The calcaneal body is then evaluated. The anterolateral fragment and the posterior tuberosity are realigned if needed to ensure that the body is anatomically reduced. The small lateral wall fragment is momentarily lifted to evaluate the defect below the joint. If a large cavity is present, the surgeon may elect to fill the void with either bone graft or a graft substitute. Once this is performed, the lateral wall remnant is placed back and an appropriately sized, low-profile lateral neutralization plate is selected and positioned (Fig. 61-36A). Bending of the plate is not recommended because the bone will come to the plate with the placement of the screws. Furthermore, bending of the plate will throw the calcaneal tuberosity into varus. 
Figure 61-36
Fixation of body.
 
A: Lateral wall replaced, and low-profile plate applied. B–D: Radiographs of final fixation, showing anatomic reduction of the articular surface, anterior process, and tuberosity.
A: Lateral wall replaced, and low-profile plate applied. B–D: Radiographs of final fixation, showing anatomic reduction of the articular surface, anterior process, and tuberosity.
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Figure 61-36
Fixation of body.
A: Lateral wall replaced, and low-profile plate applied. B–D: Radiographs of final fixation, showing anatomic reduction of the articular surface, anterior process, and tuberosity.
A: Lateral wall replaced, and low-profile plate applied. B–D: Radiographs of final fixation, showing anatomic reduction of the articular surface, anterior process, and tuberosity.
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Plate position is verified on a lateral fluoroscopic view, and then secured with cancellous 4.0-mm screws (Fig. 61-36B). These screws are placed under power, as the torque of the power driver will cause the bone to narrow as the screw pushes the plate against the lateral wall. The anterior-superior most screw hole is filled first, followed by the posterior-superior and posterior-inferior screw holes over the posterior tuberosity. As the tuberosity screws are placed, a lateral-to-medial force is applied to the plate by the surgeon’s thumb, whereas a valgus force is applied to the tuberosity by the surgeon’s long and ring fingers pulling upward on the tuberosity (Fig. 61-37). 
Figure 61-37
Fixation of tuberosity.
 
As screws are drilled into tuberosity, the surgeon applies downward pressure against plate with his thumb (narrowing width of calcaneus), with simultaneous upward lift of tuberosity with his long and ring fingers (pulling tuberosity out of varus).
As screws are drilled into tuberosity, the surgeon applies downward pressure against plate with his thumb (narrowing width of calcaneus), with simultaneous upward lift of tuberosity with his long and ring fingers (pulling tuberosity out of varus).
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Figure 61-37
Fixation of tuberosity.
As screws are drilled into tuberosity, the surgeon applies downward pressure against plate with his thumb (narrowing width of calcaneus), with simultaneous upward lift of tuberosity with his long and ring fingers (pulling tuberosity out of varus).
As screws are drilled into tuberosity, the surgeon applies downward pressure against plate with his thumb (narrowing width of calcaneus), with simultaneous upward lift of tuberosity with his long and ring fingers (pulling tuberosity out of varus).
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The three main components of the calcaneus (as described by Letournel96)—the anterior process, the posterior tuberosity, and the posterior facet articular surface—are secured to the plate with (generally) two screws placed into each component. The final reduction is verified fluoroscopically, and all K-wires are removed (Fig. 61-36C-D). 
Locking Plates
A locking calcaneal plate may alternatively be used in patients with poor bone quality, so as to limit settling of the fracture fragments. The sequence and location of screw placement is identical to that described for a nonlocking plate, followed by one or two locking screws placed beneath the articular fragments, which provide rafter support to the articular block (Fig. 61-38). 
Figure 61-38
Locking plate fixation in patient with seizure disorder and osteopenic bone with (A) lateral, (B) Broden, and (C) axial views demonstrating satisfactory reduction and fixation.
Rockwood-ch061-image038.png
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The introduction of locking plate technology has been an important advance in the treatment of complex, periarticular fractures and fractures in osteopenic bone. In cadaveric models, locked plates have generally increased the stability of fracture fixation,172 with polyaxially locked screws performing best.143,145 To date, no studies have demonstrated biomechanical or clinical superiority of locked calcaneal plates to nonlocked, low-profile neutralization plates.83,141 The indications for locking plates in the treatment of calcaneus fractures are still being defined but may include use in highly comminuted fractures, the elderly, or those with particularly poor bone stock. 
Assessment of Peroneal Tendons
Following removal of the K-wire retractors, the peroneal tendons should easily reduce into the retrofibular groove. Failure of the peroneal tendons to reduce is indicative of injury to the superior peroneal retinaculum (SPR), which will then need to be repaired in order to stabilize the tendons.42,107,162,163,168 
The peroneal tendons are evaluated by placing a Freer elevator into the peroneal tendon sheath along the undersurface of the flap and advanced proximally to the level of the lateral malleolus (Fig. 61-39A-B). The elevator is levered forward while observing the overlying skin: if the SPR remains intact, a firm endpoint will be encountered; if the SPR is detached from the lateral malleolus, no endpoint is identified and the elevator will easily slide anterior to the fibula. In general, the more lateral the articular fracture line, the greater the likelihood of injury to the SPR. The extensile lateral flap is then closed to reestablish tension on the peroneal tendon sheath, prior to the SPR repair. Because of potential wound complications with the extensile lateral incision, the SPR repair may be completed with the tourniquet deflated if insufficient time remains. 
Figure 61-39
Peroneal tendon evaluation.
 
A: After K-wires are removed, peroneal tendons are tested for instability by placing a probe within the tendon sheath. B: Verification that the tendons are stable. The probe is limited in its anterior excursion over the fibula. Tip of probe (white arrow).
A: After K-wires are removed, peroneal tendons are tested for instability by placing a probe within the tendon sheath. B: Verification that the tendons are stable. The probe is limited in its anterior excursion over the fibula. Tip of probe (white arrow).
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Figure 61-39
Peroneal tendon evaluation.
A: After K-wires are removed, peroneal tendons are tested for instability by placing a probe within the tendon sheath. B: Verification that the tendons are stable. The probe is limited in its anterior excursion over the fibula. Tip of probe (white arrow).
A: After K-wires are removed, peroneal tendons are tested for instability by placing a probe within the tendon sheath. B: Verification that the tendons are stable. The probe is limited in its anterior excursion over the fibula. Tip of probe (white arrow).
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Repair of Superior Peroneal Retinaculum
Following closure of the extensile lateral flap, a small (<3 cm) incision is made along the posterolateral edge of the lateral malleolus. The peroneal tendon sheath is incised, preserving a 1 to 2 mm cuff of retinacular tissue for later closure. The peroneal tendons are assessed for associated tendon pathology and the “false pouch” is identified (Fig. 61-40A). Two suture anchors are placed along the posterolateral rim of the lateral malleolus, and the nonabsorbable sutures are passed in horizontal mattress fashion into the detached retinaculum. The sutures are placed as anterior as possible, which tensions the SPR is toward the posterolateral rim thereby eliminating the “false pouch” (Fig. 61-40B). With the peroneal tendons held reduced in the peroneal groove, the sutures are then tied down, which reestablishes a checkrein on the peroneal tendons. Tendon stability is confirmed by taking the involved limb through a range of motion passively. The tendon sheath is closed with interrupted, figure-of-eight 2-0 nonabsorbable sutures. The wound is closed in layered fashion with interrupted 2-0 or 3-0 absorbable suture, and 3-0 monofilament suture for the skin layer using the modified Allgöwer-Donati technique.150 
Figure 61-40
Superior peroneal retinaculum (SPR) repair through a separate incision.
 
A: An incision is made over the distal fibula, and the tear is entered. Note false pouch anterior to posterolateral rim of fibula (white arrow). B: The tendons are reduced and the SPR is secured to the fibula with suture anchors to stabilize peroneal tendons.
A: An incision is made over the distal fibula, and the tear is entered. Note false pouch anterior to posterolateral rim of fibula (white arrow). B: The tendons are reduced and the SPR is secured to the fibula with suture anchors to stabilize peroneal tendons.
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Figure 61-40
Superior peroneal retinaculum (SPR) repair through a separate incision.
A: An incision is made over the distal fibula, and the tear is entered. Note false pouch anterior to posterolateral rim of fibula (white arrow). B: The tendons are reduced and the SPR is secured to the fibula with suture anchors to stabilize peroneal tendons.
A: An incision is made over the distal fibula, and the tear is entered. Note false pouch anterior to posterolateral rim of fibula (white arrow). B: The tendons are reduced and the SPR is secured to the fibula with suture anchors to stabilize peroneal tendons.
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Wound Closure
A deep drain is placed exiting at the proximal tip of the vertical limb of the incision, and the wound is closed in the following layered fashion. Deep individual no. 0 absorbable sutures are passed in a figure-of-eight fashion, starting with the apex of the wound, and advancing to the proximal and distal edges (Fig. 61-41A). The sutures are temporarily clamped until all deep sutures have been placed. Once completed, the sutures are hand-tied sequentially, starting at the proximal and distal ends and working toward the apex of the incision. This should pull the flap together and take tension off the apex of the incision. The skin layer is closed with 3-0 monofilament suture using the modified Allgöwer-Donati technique, again starting at the ends and progressing toward the apex150 (Fig. 61-41B). Sterile dressings are applied and the tourniquet is deflated. A bulky cotton dressing and Weber splint are then placed. 
Figure 61-41
Wound closure.
 
A: Individual figure-of-eight No. 0 Vicryl sutures placed from corner of wound to ends, and then individually tied from ends to corner to relieve pressure on flap edge. B: Skin closure with 3-0 nylon using Allgower-Denoti sutures with knot on periphery of incision. Note placement of drain to prevent pressure from postoperative hematoma.
A: Individual figure-of-eight No. 0 Vicryl sutures placed from corner of wound to ends, and then individually tied from ends to corner to relieve pressure on flap edge. B: Skin closure with 3-0 nylon using Allgower-Denoti sutures with knot on periphery of incision. Note placement of drain to prevent pressure from postoperative hematoma.
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Figure 61-41
Wound closure.
A: Individual figure-of-eight No. 0 Vicryl sutures placed from corner of wound to ends, and then individually tied from ends to corner to relieve pressure on flap edge. B: Skin closure with 3-0 nylon using Allgower-Denoti sutures with knot on periphery of incision. Note placement of drain to prevent pressure from postoperative hematoma.
A: Individual figure-of-eight No. 0 Vicryl sutures placed from corner of wound to ends, and then individually tied from ends to corner to relieve pressure on flap edge. B: Skin closure with 3-0 nylon using Allgower-Denoti sutures with knot on periphery of incision. Note placement of drain to prevent pressure from postoperative hematoma.
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Postoperative Care
The patient is maintained overnight in the hospital for pain control, and placed in a short-leg non–weight-bearing cast the following morning prior to discharge. The patient is then evaluated at 3 weeks postoperatively. At that time, the cast is removed and the incision is assessed. The sutures are removed if the incision is fully sealed and completely dry. If not, the sutures may stay in place for another 2 to 4 weeks. Sutures should not be removed until the wound is fully sealed and dry. The patient is converted back into the elastic stocking, and fracture boot is locked in neutral flexion. Early ankle and subtalar joint range-of-motion exercises out of the boot are initiated at this time; however, weight bearing is not permitted until 12 weeks postoperatively. In addition, the authors prefer that the patient sleep in the boot until weight bearing is initiated to prevent an equinus contracture. Once weight bearing is initiated, the patient is gradually transitioned into regular shoes as tolerated. The patient should be able to return to a reasonably active job by 4.5 to 6 months postoperatively. 
Potential Pitfalls and Preventative Measures for ORIF Through an Extensile Lateral Approach for Joint-Depression Fractures.
Although it is nearly impossible to describe every possible reduction maneuver or potential pitfall with joint depression type calcaneal fractures, a few potential pitfalls bear mention. If the superolateral fragment won’t reduce to the sustentacular fragment due to impingement from the calcaneal tuberosity, the tuberosity should be levered through the Schanz pin into extreme varus and medial translation. Further impinging bone can be curetted away from the tuberosity, or even removed (temporarily) with an osteotome, and replaced following the articular reduction (Table 61-7
If the articular surface won’t align with the anterior process, such that the crucial angle of Gissane cannot be restored, the superolateral articular fragment should reassessed to ensure that the fragment isn’t translated anteriorly relative to the sustentacular fragment. Similarly, the anterolateral fragment should be reassessed to ensure that the fragment isn’t translated posteriorly relative to the anterior main fragment. Additionally, the junction of the sustentacular fragment and anterior main fragment should be reassessed for the presence of a transverse (primary) fracture line with forward rotation of the sustentacular fragment beneath the anterior main fragment. 
If the tuberosity won’t properly reduce or align to the remaining calcaneal body, the tuberosity should be re-reduced with the knee in flexion and the ankle in plantarflexion to relax the upward pull of the gastrocnemius against the tuberosity. In severe cases, a laminar spreader can be used between the tuberosity and the posterior distal tibia to assist with restoration of overall length. 
 
Table 61-7
ORIF of Intra-Articular Calcaneus Fractures
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Table 61-7
ORIF of Intra-Articular Calcaneus Fractures
Potential Pitfalls and Preventions
Pitfall Preventions
Superolateral fragment won’t reduce to sustentacular fragment due to impingement from calcaneal tuberosity Lever calcaneal tuberosity through Schanz pin into extreme varus and medial translation
Curette away any impinging bone from the tuberosity fragment
(Temporarily) remove (and later replace) small portion of tuberosity fragment with osteotome
Articular surface won’t align with anterior process (crucial angle of Gissane) Reassess superolateral fragment to ensure fragment isn’t translated anteriorly relative to sustentacular fragment; and reduction of anterolateral fragment relative to anterior main fragment
Reassess for presence of transverse fracture line and forward rotation of sustentacular fragment beneath anterior main fragment
Tuberosity won’t reduce/align to remaining calcaneal body Rereduce tuberosity with knee in flexion and ankle in plantarflexion to relax the upward pull of gastrocnemius against tuberosity
Use laminar spreader between tuberosity and posterior distal tibia to restore overall length
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ORIF Through Extensile Lateral Approach for Intra-Articular Split Tongue Fractures

Whereas simple extra-articular tongue fractures (Sanders type IIC) can be reduced using the modified methods of Essex-Lopresti,54 it is virtually impossible to close reduce even a simple two-part tongue fracture when an intra-articular fracture is also present in the sagittal plane, such as a Sanders type IIA or IIB (Fig. 61-42). Although the fragments can be elevated, an anatomic reduction of the joint cannot be obtained. The reason for this is that it is simply impossible to (a) clear the bone, soft tissue debris, and clot from the fracture surfaces and (b) rotate and manipulate the fragments into a three-dimensional anatomic position percutaneously. Tongue fractures that are highly comminuted, such as Sanders type III or IV fractures, will have a similar problem. In these cases, ORIF through a lateral approach is required with certain caveats. 
Figure 61-42
Split-tongue–type fracture.
 
A: When these are opened and the tongue is disimpacted, a defect can be seen on its medial edge (black outline, white arrow). B: Further dissection reveals free osteocondral fragment (in pituitary rongeur).
A: When these are opened and the tongue is disimpacted, a defect can be seen on its medial edge (black outline, white arrow). B: Further dissection reveals free osteocondral fragment (in pituitary rongeur).
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Figure 61-42
Split-tongue–type fracture.
A: When these are opened and the tongue is disimpacted, a defect can be seen on its medial edge (black outline, white arrow). B: Further dissection reveals free osteocondral fragment (in pituitary rongeur).
A: When these are opened and the tongue is disimpacted, a defect can be seen on its medial edge (black outline, white arrow). B: Further dissection reveals free osteocondral fragment (in pituitary rongeur).
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After lateral exposure of the fracture, attempts to anatomically reduce a type IIA or IIB tongue fragment in proper rotation in the sagittal plane may be virtually impossible because of the constant deforming force of the Achilles tendon. Similarly, after repositioning of the middle fragment to the sustentaculum using resorbable pins, the surgeon attempting reduction of the lateral type III tongue fragment will suffer the same fate. A solution to this is to perform the Essex-Lopresti maneuver on the tongue fragment in an open manner. Terminally threaded guide pins from a large cannulated screw set or a 4.5-mm Schantz pin may be used. This invariably reduces the fragment anatomically in the sagittal plane. The fragment can then be pinned to the sustentacular fragment and the procedure completed (as described previously). 

Reduction and Fixation of Fracture–Dislocations of the Calcaneus

The calcaneal fracture component to fracture dislocation injuries is usually a simple split. As such, if the dislocation can be reduced, the fracture usually will recoil into an anatomic position. To accomplish this, however, reduction must occur sooner rather than later. Therefore, when a fracture–dislocation is suspected, CT scans should be obtained immediately to verify the diagnosis, and surgery should be performed soon thereafter. If there is a significant time delay, the fracture will be exceedingly difficult to reduce without a formal open reduction. 
The patient is brought into the operating room and placed in the lateral position in the standard manner (as previously noted). A fluoroscopic lateral is obtained to identify the superior lateral edge of the displaced tuberosity fragment. A 1-cm oblique skin incision is made directly over this area, carefully avoiding the peroneal tendons and sural nerve. A periosteal elevator is inserted into the wound and manipulated carefully until it is in the fracture, hugging the medial surface of the lateral fragment. It is advanced until it is below the talus and within the subtalar joint. Because this displaced portion of the joint is initially wedged up against the lateral side of the talus, positioning of the elevator should be verified on radiography to ascertain that it is not in the ankle joint. Once satisfied that the elevator is in the correct position, the surgeon should attempt to lever the lateral fragment downward. As soon as it clears the talus, it will recoil back into position. 
At this point, the surgeon can elect to wait until soft tissue swelling is gone and fix the fracture and the remaining lateral pathology at 10 to 21 days, or proceed with percutaneous fixation of the fracture and repair of the collateral ligaments and peroneal tendons at the same time. If the surgeon sees excess comminution, or is unable to reduce the articular surface anatomically after reducing the dislocation, a delay is advisable. 
If fixation is immediately attempted, one tine of a large periarticular reduction is passed through the lateral incision to grab the lateral fragment, whereas the other tine is placed on the sustentaculum, medially. A clamp of this design is needed to negotiate around the body of the calcaneus. Once the two fragments are between the clamp tines, the clamp is slowly closed, sliding the fragments down and together in a reduction maneuver. The reduction is verified on intraoperative fluoroscopic Broden views and, once acceptable, secured with percutaneously placed 1.6-mm K-wires, inserted from lateral to medial in the coronal plane. When satisfied with the final position of the articular surface and the K-wires, a small incision is made over each wire, and a cannulated 4.0-mm screw of appropriate length is placed. The clamp is then removed. 
Attention is then turned to the collateral ligaments and peroneal tendons. The initial incision is usually exactly at the level of the pathology and can be extended in either direction to expose the ligaments and the tendons. The tendons can typically be pushed back into their sulcus. They should then be tested for stability by dorsiflexing and plantarflexing the ankle. If the tendons repeatedly sublux or dislocate, the sheath has been torn from the fibula, allowing the tendons to slip over the lateral malleolus. Using suture anchors, the sheath can be secured to the posterior inferior edge of the malleolus to reestablish the peroneal checkrein and stabilize the peroneal tendons within their groove (Fig. 61-40A-B). At this point, the lateral ligamentous complex of the ankle is evaluated and primarily repaired, again with suture anchors, either in the fibula or the talus, depending on the pathology encountered. For midsubstance tears, anchors are placed in both the talus and the fibula, and the suture is woven through the remnants of the ligament and then sewn to each other. Postoperatively, the patient is placed in a padded Weber splint. This is changed for a short-leg non–weight-bearing cast for 6 weeks. Thereafter, the cast is exchanged for a compression stocking and fracture boot, and range of motion of the subtalar and ankle joint is begun. Weight bearing is permitted after radiographic determination of fracture healing, typically at 10 to 12 weeks. 

Open Reduction with Internal Fixation Combined with Primary Subtalar Arthrodesis

In fractures with a significant degree of articular comminution, patients must be counseled beforehand about the possible intraoperative decision to perform a primary subtalar fusion, and this possible procedure should be added to the surgical consent. 
Primary subtalar arthrodesis is indicated only for highly comminuted intra-articular fractures (typically severe Sanders type III and all types IV), after attempts at internal fixation of the posterior facet have failed because the articular surface is not reconstructable.154 In these cases it must be emphasized that a standard ORIF using an extensile lateral approach is performed as earlier described, such that the best restoration of the anatomy of the entire calcaneus is obtained. Once the relationships between the calcaneal tuberosity, anterior process, and posterior facet fragments have been reestablished using plates and screws, the joint is critically evaluated. If (a) the joint is poorly reduced, (b) severe cartilage delamination exists, or (c) much of the joint surface is absent, then a decision is made to perform a primary subtalar fusion (Fig. 61-43). 
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Figure 61-43
Primary fusion for a type IV fracture.
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In this procedure, the remaining cartilage is removed from the surfaces of the posterior facet (calcaneus and talus) while preserving the subchondral bone. The subchondral surfaces of the talus are perforated with a 2.5-mm drill bit to create a bleeding surface, and cancellous autograft or allograft is placed in the subtalar joint space. The arthrodesis is then performed using one or two large (6.5 to 8.0 mm) cannulated lag screws, placed into the corner of the heel such that the screws lie perpendicular to the subtalar joint and enter the dome of the talus. If the 3.5-mm articular lag screw interferes with the placement of the arthodesis screws, it is removed; however, care should be taken to leave the screws within the plate in place so that the posterior facet is still connected to the rest of the calcaneus via the plate and the overall reduction is maintained. If necessary, the latter screws can be redirected. Wound closure is as previously described. The patient is kept nonweight bearing in serial short-leg casts for 10 to 12 weeks, until radiographic healing of both the fracture and the arthrodesis is confirmed. Progressive weight bearing is initiated thereafter, following the same regimen as described earlier. 

Open Reduction with Internal Fixation of Anterior Process of the Calcaneus Fractures

We prefer open reduction and internal fixation of anterior process fractures if the fragment is greater than 25% of the calcaneocuboid articulation as seen on CT scan evaluation. 
The anterior process lies just distal to the sinus tarsi and can be easily felt on palpation. The patient is placed in the supine position with a bolster under the hip or, alternately, in a lateral decubitus position. A lateral longitudinal incision is made directly over the anterior process. The extensor digitorum brevis muscle is mobilized; it is usually not necessary to mobilize the more plantar peroneus brevis tendon. The calcaneocuboid joint is exposed, and the fracture is identified, reduced, and provisionally stabilized with 1.2- to 1.6-mm K-wires. The reduction is verified fluoroscopically and is best seen on an oblique view of the foot. Definitive fixation is achieved with small- or minifragment screws. In the event of comminution, these fragments may be buttressed with a mini-fragment plate placed parallel to the articular surface of the calcaneocuboid joint (Fig. 61-44). Comminuted fragments too small to accept fixation may be primarily excised; however, every attempt is made to preserve as much articular surface as possible. The incision is closed in a layered fashion, a bulky splint is applied. The patient is converted to a compression stocking and fracture boot at 2 weeks postoperatively, at which point range-of-motion exercises are begun. Weight bearing is typically permitted at 6 weeks postoperatively; in the event of fragment excision, weight bearing is begun at 2 weeks postoperatively once the incision has sufficiently healed. 
Figure 61-44
Anterior process of calcaneus fracture.
 
A: Lateral CT showing impaction of cuboid into anterior process. B: Intraoperative view. Note articular stepoff and impaction (white arrows). C: Fixation with mini-fragment screws and buttress plate.
A: Lateral CT showing impaction of cuboid into anterior process. B: Intraoperative view. Note articular stepoff and impaction (white arrows). C: Fixation with mini-fragment screws and buttress plate.
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Figure 61-44
Anterior process of calcaneus fracture.
A: Lateral CT showing impaction of cuboid into anterior process. B: Intraoperative view. Note articular stepoff and impaction (white arrows). C: Fixation with mini-fragment screws and buttress plate.
A: Lateral CT showing impaction of cuboid into anterior process. B: Intraoperative view. Note articular stepoff and impaction (white arrows). C: Fixation with mini-fragment screws and buttress plate.
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Occasionally, symptomatic fibrous unions or nonunions of the anterior process are encountered. The operative approach remains the same; treatment is based on size of fragment. If large enough to accept a mini-fragment screw, attempts can be made to debride the interface back to bleeding bone and then secure the fragment with a lag screw. If the fragment is not repairable, excision and soft tissue reconstruction are performed. Postoperative management is the same as for acute injuries with weight bearing initiated after wound healing. 

Open Reduction with Internal Fixation of Calcaneal Tuberosity (Avulsion) Fractures

The patient is placed in the prone position, which allows access to both the medial and lateral sides of the calcaneus as needed to reduce the fracture; the lateral decubitus position may alternatively be used. For smaller fragments where the entire Achilles tendon insertion is involved, a posterior approach may be preferable. A large bolster should be placed under the foot to flex the knee and relax the calf muscles. The patient should be paralyzed to maximally relax the gastrocnemius-soleus complex. The vertical limb of an extensile lateral incision is made, centered over the fracture. On entering the fracture, it should be cleaned of clot and loose bone. Using a periosteal elevator, enough soft tissue should be cleared from the superior and inferior calcaneus to allow the insertion of pointed reduction forceps. Often, a second clamp is necessary to fully compress the fracture into an anatomic position, and manipulation of the foot and leg may be needed to complete the reduction. Because of the tension placed on the fracture by the calf muscles, the reduction may take several minutes to accomplish. Alternatively, and especially with larger beak fractures, which feature an obliquely oriented fracture line extending toward the posterior facet, two terminally threaded guide pins may be placed within the beak fragment perpendicular to the fracture line, and levered plantarward to approximate the fracture fragments. The reduction can then be anatomically reduced with pointed reduction forceps. 
Although large cannulated lag screws or multiple small-fragment cortical lag screws can be placed perpendicularly across the fracture (Fig. 61-45), late separation of the fracture can occur because of pull of the gastrocnemius-soleus complex. Therefore, it is often necessary to add cerclage wire to the fixation (Fig. 61-46). First popularized by Weber,23 the addition of a tension band effectively neutralizes the force across any size fracture fragment. This wire (18 or 20 gauge) should be inserted through the lateral incision over the posterior superior aspect of the calcaneus, anterior to the Achilles tendon, using a curved wire passer. When the tip of the passer is palpated on the medial skin, a small incision is made, and the wire is advanced through the incision (Fig. 61-46A). The wire is clamped, and the passer is removed through the lateral wound. It is then repassed from lateral to medial, without any wire, along the inferior portion of the calcaneus, in the space just anterior to the tubercles and superior to the plantar fascial insertion (Fig. 61-46B). It is manipulated to exit out of the previously made medial incision, and the wire is then threaded into it and pulled back out of the lateral wound (Fig. 61-46D). The wire should be unlooped as it is passed through the calcaneus, so as to avoid kinking of the wire. At this point, the wire passer is removed and the wire tightened snugly. It is bent back flush with the lateral wall, and any excess knot is cut off with wire cutters (Fig. 61-46D and E). 
Figure 61-45
Calcaneal beak/tuberosity avulsion fracture.
 
A. Sagittal CT showing no intra-articular involvement. B. Fixation with small-fragment cortical lag screws.
A. Sagittal CT showing no intra-articular involvement. B. Fixation with small-fragment cortical lag screws.
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Figure 61-45
Calcaneal beak/tuberosity avulsion fracture.
A. Sagittal CT showing no intra-articular involvement. B. Fixation with small-fragment cortical lag screws.
A. Sagittal CT showing no intra-articular involvement. B. Fixation with small-fragment cortical lag screws.
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Figure 61-46
Calcaneal beak/tuberosity avulsion fracture.
 
Cerclage fixation according to BG Weber.
Cerclage fixation according to BG Weber.
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Figure 61-46
Calcaneal beak/tuberosity avulsion fracture.
Cerclage fixation according to BG Weber.
Cerclage fixation according to BG Weber.
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In late cases, or if the pull of the gastrocnemius-soleus complex seems excessive to where fracture healing may be jeopardized, a gastroc recession or Achilles tendon lengthening may be completed.129,130 Following wound closure, the limb is immobilized in a bulky cotton dressing and Weber splint with the ankle in plantarflexion, so as to neutralize the forces across the fracture site. The patient is converted to a compression stocking and fracture boot with a 2 in heel wedge, and gentle active early range-of-motion exercises are initiated at 2 weeks postoperatively. Weight bearing is not begun until 6 to 8 weeks postoperatively, at which point the patient is transitioned into regular shoe wear. 

Outcomes for ORIF of Calcaneus Fractures

The majority of recent published series on operative treatment of calcaneal fractures have used a lateral approach through which reduction of the calcaneal body and restoration of calcaneal height, length, and width was consistently reproducible, irrespective of the extent of comminution.12,14,15,25,48,49,56,82,96,98,99,110,111,152,154,176,192196 In addition, the articular reduction, when technically possible, was attainable through this lateral approach, such that a supplemental medial approach was rarely needed.87 Six separate large series of displaced intra-articular calcaneus fractures (representing 979 fractures), treated surgically through a lateral approach alone, confirmed that good results are possible with operative treatment.14,97,154,194 
Sanders et al.154 reported on 132 displaced intra-articular calcaneal fractures (types II through IV) using their CT classification system. One hundred twenty patients returned for follow-up at an average of 29 months. All fractures were managed through a lateral approach with lag screw fixation of the posterior facet, plate fixation of the calcaneal body, and no bone grafting. All patients underwent CT evaluation preoperatively, postoperatively, and at 1-year follow-up. Clinical outcome was based on the Maryland Foot Score; those cases requiring subsequent subtalar arthrodesis for post-traumatic arthritis were immediately considered failures. Calcaneal height, length, and width were restored to 98%, 100%, and 110% of normal, respectively, regardless of fracture type. Bohler and Gissane angles were reduced within 5 degrees of normal in all except three fractures. 
In type II fractures, 68 of 79 fractures (86%) had an anatomic reduction of the articular surface as verified by follow-up evaluation, 10 had near-anatomic (within 2- to 3-mm) reductions, and one had an approximate (within 4- to 5-mm) reduction. Clinically, 58 fractures (73%) had good or excellent results. Eight fractures (10%) had a fair result and 13 were considered failures, with 10 of these 21 requiring a subtalar arthrodesis. In all 10 of these cases, arthrography, CT, and subsequent visual inspection of the joint at time of subtalar arthrodesis verified an anatomically reduced articular surface with damaged cartilage. 
In type III fractures, 18 of 30 fractures (60%) had an anatomic reduction of the posterior facet, 8 had near-anatomic reductions, and 4 had approximate reductions. Twenty-one fractures had good or excellent results, three had fair results, and there were six failures. Of the seven fractures that ultimately required a subtalar arthrodesis, four had been anatomically reduced. 
In type IV fractures, there were no anatomic, three near-anatomic, and two approximate reductions with six complete failures (5 mm of greater step-off). Clinically, there was one good result, two fair results, and eight complete failures; the one good and two fair results were in the three patients with near-anatomic reductions. The authors concluded that while an anatomic articular reduction was needed to obtain a good or excellent result, it could not guarantee it, likely because of articular cartilage injury at the moment of impact. Furthermore, clinical prognostication was possible because good-to-excellent results decreased as the number of articular fracture fragments increased. Finally, worse results occurred at the start of the series, while the number of good-to-excellent outcomes improved each successive year. It became apparent that type II fractures were easier to fix than type III fractures; however, with time, even type III results improved. The results of operative intervention in type IV fractures were not improved even after 4 years of experience. 
Other recently published reports are similar in their use of CT scans, extensile lateral approaches, plate and screw fixation, and clinical assessment using standardized tools.37,38,41,82,93,99,116,165,176,178 These studies all used either the Crosby and Fitzgibbons or the Sanders classifications, and either the Maryland Foot Score or the Creighton-Nebraska Assessment tool,37 thus allowing comparison between studies. As a result, the studies of Crosby and Fitzgibbons,38 Songet al.,165 Thordarson and Kreiger,176 Laughlin et al.,93 and Tornetta178 suggest that operative intervention, when properly executed, can achieve good results. In addition, classifications based on CT appear to be prognostic: the more comminuted the articular surface, the worse is the prognosis, thus confirming the findings of Sanders et al.154 

Management of Expected Adverse Outcomes and Unexpected Complications in Calcaneus Fractures (Table 61-8)

 
Table 61-8
Calcaneus Fractures
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Table 61-8
Calcaneus Fractures
Common Adverse Outcomes and Complications
  •  
    Wound complications/calcaneal osteomyelitis
  •  
    Peroneal tenosynovitis/stenosis/dislocation
  •  
    Post-traumatic subtalar arthritis/calcaneocuboid arthritis/calcaneal malunion
  •  
    Ankle pain
  •  
    Heel pad pain/exostosis
  •  
    Nerve injury/entrapment
X

Wound Complications and Calcaneal Osteomyelitis

The most common complication following operative treatment of a calcaneal fracture is wound dehiscence, and this may occur in up to 25% of cases.11,12,58,75,80,100,101,154 The incision typically will approximate relatively easily; however, the wound may later dehisce, up to 4 weeks following surgery, and most commonly at the apex of the incision. Risk factors for wound dehiscence and wound complications in general include smoking, diabetes, open fractures, high body mass index, and a single layered closure.2,58 The majority of the wounds will eventually heal; deep infection and osteomyelitis develops in approximately 1% to 4% of closed fractures11,76,80,101 and in up to 19% of open fractures.4,11,13,78 
In the event of a wound dehiscence, all range-of-motion exercises should be stopped so as to prevent further dehiscence, and a course of oral antibiotics is prescribed. The limb may be placed in a cast with a window over the wound, and damp-to-dry dressing changes or other granulation-promoting wound agents are started on a daily basis (Fig. 61-47). Alternately, or in the event of significant drainage, the patient may be placed in a fracture boot, and the wound managed with daily whirlpool treatments. This regimen is usually successful, so long as the wound is limited to a partial-thickness necrosis of the skin. Once the wound is healed, range-of-motion exercises are reinstituted. 
Figure 61-47
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Figure 61-47
Wound dehiscence.
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A negative pressure device may be beneficial for larger, more extensive wounds or recalcitrant wounds to accelerate wound granulation. This device may also be used as a preventive measure at the time of initial wound closure.167 If all treatment methods have failed, a low-profile fasciocutaneous flap such as a lateral arm flap may be needed.100 
If gross purulence is encountered, hospitalization with serial surgical debridements and the administration of culture-specific antibiotics must be started. These problems are usually seen in the early postoperative period, and as such, most patients have not developed diffuse osteomyelitis but rather superficial osteitis because of direct extension from an adjacent source.30 If the infection is relatively superficial, the plate and screws should be retained, at least until the fracture has healed (typically a minimum of 6 months). After the wound bed is determined to be clean, a delayed closure, or the use of a vacuum-assisted device, is attempted if at all possible. If the wound is too large to treat with the latter methods, a free tissue transfer is performed. Culture-specific intravenous antibiotics are administered for a minimum of 6 weeks. In the event of diffuse osteomyelitis, all implants must be removed along with all necrotic and infected bone. In this case, an antibiotic impregnated spacer should be placed in the wound. Following repeated debridements and 6 weeks of culture-specific antibiotics, the patient is readmitted to the hospital, serial debridements are performed, wound cultures are obtained, and, if the defect is clean, a subtalar fusion using a large structural iliac crest autograft can be performed, based on the amount of remaining calcaneal bone stock. In rare instances, this will not be possible and an amputation will be required, but this is the exceptional situation. 

Peroneal Tenosynovitis and Stenosis

Peroneal tenosynovitis and stenosis are generally seen following nonoperative treatment because of lateral impingement, where the displaced, expanded lateral wall subluxes the peroneal tendons against the distal tip of the fibula, or dislocates the tendons. Entrapment may also occur after operative treatment166 and is more common with a standard Kocher approach, because the tendons are released from their sheath to allow access to the subtalar joint. The extensile lateral approach has largely circumvented these problems70,182; however, care must be taken when operating near the fibula to sublux, but not dislocate, the peroneal tendons when exposing the fracture. 
Patients may also develop adhesions and scarring of the tendons, either from the surgical approach or from prominent adjacent implants. Nonoperative management includes nonsteroidal anti-inflammatory medication, and physical therapy for manual mobilization, stretching and eversion strengthening. If these modalities fail to provide relief, a peroneal tenolysis and/or removal of the symptomatic implants may be necessary. 

Peroneal Tendon Dislocation

Peroneal tendon dislocation typically occurs in joint-depression–type patterns, from the explosion and relative shortening of the lateral calcaneal wall as the superolateral articular fragment is impacted into the calcaneal body, and in fracture–dislocation variant patterns, in which the tuberosity with the attached superolateral fragment is driven into the talofibular joint. In general, the more lateral the articular fracture line, the greater the likelihood of injury to the SPR. 
The diagnosis can occasionally be made preoperatively, by palpation along the lateral malleolus (Fig. 61-48), but in most instances, the tendon dislocation is identified intraoperatively, at the time of wound closure. In this case, the SPR should be repaired so as to stabilize the peroneal tendons, and is most easily performed by tacking the periosteal sleeve down to the posterolateral rim of the fibula with staples or suture anchors to prevent the tendons from redislocating into the soft tissue defect created by the injury (Fig. 61-48).42,107,162,163,168 
Figure 61-48
Peroneal tendon dislocation.
 
A: Reduced. B: Tendons dislocated over fibula. C: Normal anatomy. D: Tendon sheath avulsion with tendon dislocation. E: Repair of sheath using small staples. F: Repair of sheath using suture anchors.
A: Reduced. B: Tendons dislocated over fibula. C: Normal anatomy. D: Tendon sheath avulsion with tendon dislocation. E: Repair of sheath using small staples. F: Repair of sheath using suture anchors.
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A: Reduced. B: Tendons dislocated over fibula. C: Normal anatomy. D: Tendon sheath avulsion with tendon dislocation. E: Repair of sheath using small staples. F: Repair of sheath using suture anchors.
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Figure 61-48
Peroneal tendon dislocation.
A: Reduced. B: Tendons dislocated over fibula. C: Normal anatomy. D: Tendon sheath avulsion with tendon dislocation. E: Repair of sheath using small staples. F: Repair of sheath using suture anchors.
A: Reduced. B: Tendons dislocated over fibula. C: Normal anatomy. D: Tendon sheath avulsion with tendon dislocation. E: Repair of sheath using small staples. F: Repair of sheath using suture anchors.
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A: Reduced. B: Tendons dislocated over fibula. C: Normal anatomy. D: Tendon sheath avulsion with tendon dislocation. E: Repair of sheath using small staples. F: Repair of sheath using suture anchors.
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Subtalar Arthritis

One of the goals of internal fixation is an anatomic reconstruction of the joint surface of the posterior facet. Patients will develop rapid deterioration of the joint if the reduction is inadequate, if screws protrude into the joint, or if the articular cartilage has been extensively damaged at the time of injury. Severe pain and disability will certainly result.119,124,154 Poeze et al.131 showed a significant inverse correlation between institutional fracture volume and the rate of late subtalar arthrodesis, suggesting the presence of true learning curve. 
Subtalar arthritis may develop, however, even in cases with a truly anatomic reduction, as a result of cartilage damage at the time of injury.152 This has been shown to be true in an experimental model by Borelli et al.,18 where the authors proved that profound and possibly irreversible articular cartilage damage occurs after a single high-energy impact load. 
If post-traumatic arthritis is present clinically and radiographically, it should be confirmed as the source of the pain.124 This can be accomplished by injecting a local anesthetic into the subtalar joint, which should relieve the pain. Nonoperative treatment includes nonsteroidal anti-inflammatory agents, and shoe modifications, such as a lace-up style ankle brace or a University of California Berkeley Laboratory orthosis. If these measures fail, implant removal and an in situ subtalar arthrodesis using 6.5- to 8.0-mm large cannulated lag screws are recommended31,57,134 (Fig. 61-49). 
Figure 61-49
In-situ subtalar arthrodesis for post-traumatic arthritis following ORIF.
 
Note prior anatomic restoration of calcaneal height and overall morphology.
Note prior anatomic restoration of calcaneal height and overall morphology.
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Figure 61-49
In-situ subtalar arthrodesis for post-traumatic arthritis following ORIF.
Note prior anatomic restoration of calcaneal height and overall morphology.
Note prior anatomic restoration of calcaneal height and overall morphology.
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Calcaneocuboid Arthritis

Calcaneocuboid joint arthritis can occur following operative treatment, most commonly if the anterolateral fragment is not perfectly repositioned, as well as with nonoperative treatment of the fracture. If the joint appears to be the area of pain, an injection of local anesthetic can be performed to differentiate between arthritis and peroneal tendonitis. In cases where it is the site of pain, similar nonoperative treatment is offered followed by an exostectomy or arthrodesis if all other methods fail.156 

Calcaneal Malunions

Many surgeons still elect to treat calcaneal fractures nonoperatively, because of either a lack of familiarity with operative techniques or fear of potential operative complications.102,132 Nonoperative management of a displaced intra-articular calcaneal fracture can result in equally problematic complications including (a) post-traumatic subtalar and/or calcaneocuboid arthritis from residual joint surface incongruity; (b) subfibular impingement because of residual expansion of the lateral calcaneal wall and subsequent heel widening; (c) peroneal tendon impingement, subluxation, or dislocation, caused in part by the subfibular bony impingement, and resulting in pain and instability; (d) loss of calcaneal height resulting in relative dorsiflexion of the talus in the ankle mortise, leading to anterior impingement and loss of ankle dorsiflexion; (e) residual hindfoot malalignment resulting in altered gait patterns and shoe wear; and (f) posterior tibial or sural neuritis.21,28,33,34,61,88,104,112,119,147,155,166 These problems affect function of the ankle, subtalar, and calcaneocuboid joints and result in pain and disability in a surprisingly large number of patients. In an effort to improve the outcome, treatment must focus on correction of the specific sequelae of calcaneal malunions (Fig. 61-50). 
Figure 61-50
Calcaneal malunion.
 
Note widened calcaneal body with fibular abutment, dislocation of peroneal tendons, and severe subtalar (A) and calcaneocuboid (B) arthritis.
Note widened calcaneal body with fibular abutment, dislocation of peroneal tendons, and severe subtalar (A) and calcaneocuboid (B) arthritis.
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Figure 61-50
Calcaneal malunion.
Note widened calcaneal body with fibular abutment, dislocation of peroneal tendons, and severe subtalar (A) and calcaneocuboid (B) arthritis.
Note widened calcaneal body with fibular abutment, dislocation of peroneal tendons, and severe subtalar (A) and calcaneocuboid (B) arthritis.
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As early as 1921, Cotton33 identified residual problems following calcaneal fractures, accurately describing the residual lateral wall expansion that limited subtalar joint motion and caused painful subfibular and peroneal tendon impingement. He performed an aggressive exostectomy of the lateral calcaneal wall, along with an extra-articular osteotomy for heel malalignment, resection of symptomatic plantar heel spurs, and forceful manipulation of the subtalar joint as described by Gleich in 1893.69 The results of his technique were indeed impressive and were duplicated by Magnuson, who used a large bone wrench to pry open the subtalar joint.104 Kalamchi and Evans88 combined the technique of Conn32 with the Gallie fusion,61 using the lateral exostosis as autograft. They noted that the trapezoidal slot for the graft allowed for correction of heel valgus, thus realigning and stabilizing the heel in neutral position, and reported good results in six patients. Braly et al.21 performed a lateral wall exostectomy combined with a peroneal tenolysis as an alternative to subtalar arthrodesis in patients with calcaneal malunions with lateral pain. They reported good results in 9 of 11 patients. 
Carr et al.28 published their preliminary results with a subtalar distraction bone block arthrodesis, which was a modification of the Gallie fusion technique.61 They used a femoral distractor medially and a differentially wedged tricortical iliac crest bone graft to restore the talocalcaneal angle, thus correcting the horizontal talus and the talonavicular subluxation. Fixation was achieved with 6.5-mm fully threaded cancellous screws placed in nonlag fashion to prevent compression of the autograft. Although good results were reported in six of eight patients, complications included one nonunion and two varus malunuions. Other authors have reported similar problems using this technique. Buch et al.24 reported good results in only 7 of 14 patients, and 2 patients had varus malunions requiring reoperation. Sanders et al.155 reported 4 varus malunions in a series of 15 patients, of whom 2 required reoperation. Bednarz et al.10 reported on 29 ft treated with a subtalar distraction bone block arthrodesis with a mean follow-up of 33 months. Four patients developed a symptomatic nonunion, all of whom were smokers, whereas 2 went on to varus malunion. In contrast, Trnka et al.181 reported on 41 ft managed with subtalar distraction bone block arthrodesis, 29 of which were calcaneal malunions, at a mean follow-up of 70 months. Although five patients went on to nonunion, there were no varus malunions in their series. 
Romash147 described a complex calcaneal osteotomy through the primary fracture line for management of calcaneal malunions. The tuberosity fragment was translated beneath the sustentacular fragment medially, thereby restoring calcaneal height and residual varus angulation. He reported satisfactory results in 9 of 10 ft at an average follow-up of 14 months. 
Stephens and Sanders169 developed a treatment algorithm based on a CT scan classification of calcaneal malunions (Fig. 61-51). Type I malunions included a large lateral exostosis, with or without extremely lateral subtalar arthrosis. Type II malunions included a lateral wall exostosis combined with subtalar arthrosis across the width of the joint. Type III malunions included a lateral exostosis, severe subtalar arthrosis, and a calcaneal body malunited in hindfoot varus or valgus angulation. An extensile lateral approach was used in all patients, and treatment was specific to malunion type: type I malunions underwent a lateral wall exostectomy and a peroneal tenolysis, as described by Cotton34 and Magnuson104; type II malunions underwent a lateral wall exostectomy, a peroneal tenolysis, and an in situ subtalar arthrodesis, using the local bone as graft as described by Kalamchi and Evans88; and type III malunions underwent a lateral wall exostectomy, a peroneal tenolysis, a subtalar fusion, and a calcaneal osteotomy to correct hindfoot malalignment or shortening, as described by Dwyer.47 Their preliminary results included 26 malunions at an average follow-up of 32 months. There were no nonunions, no varus malunions, and no deep infections, and the classification and protocol proved to be prognostic of outcome. 
Figure 61-51
Calcaneal malunions according to Stephens and Sanders.
 
Type I, lateral wall exostosis; type II, lateral wall exostosis and subtalar arthritis; type III, lateral wall exostosis, subtalar arthritis, and angular deformity.
Type I, lateral wall exostosis; type II, lateral wall exostosis and subtalar arthritis; type III, lateral wall exostosis, subtalar arthritis, and angular deformity.
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Figure 61-51
Calcaneal malunions according to Stephens and Sanders.
Type I, lateral wall exostosis; type II, lateral wall exostosis and subtalar arthritis; type III, lateral wall exostosis, subtalar arthritis, and angular deformity.
Type I, lateral wall exostosis; type II, lateral wall exostosis and subtalar arthritis; type III, lateral wall exostosis, subtalar arthritis, and angular deformity.
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Clare et al.31 reported the intermediate to long-term results of this protocol. Forty-five malunions in 40 patients were available for follow-up evaluation at a minimum of 24 months, with an average of 5.3 years (range, 24 to 151 months). Thirty-seven of 40 arthrodeses (92.5%) achieved initial union, with 42 of 45 malunions (93.3%) aligned in neutral or neutral-slight valgus hindfoot alignment. All 45 malunions were plantigrade. Statistical analysis revealed no significant difference in the Maryland Foot Score, AOFAS Ankle and Hindfoot Score, SF-36 Health Survey subscales, lateral talocalcaneal, talar declination, or calcaneal pitch angles among the three malunion groups. Smoking was a significant risk factor for nonunion of the fusion and wound complications in the series. 
Despite these good results, Radnay et al.134 completed a matched-cohort study comparing patients who had undergone initial ORIF and subsequently developed post-traumatic arthritis requiring an in situ fusion to patients treated nonoperatively who developed a calcaneal malunion requiring late reconstruction and subtalar arthrodesis. The ORIF group included 36 ft in 34 patients with an average follow-up of 2.7 years. The average interval from ORIF to late subtalar arthrodesis was 22 months, and 33 of 36 arthrodeses (91.7%) achieved initial union. The calcaneal malunion group included 45 ft in 40 patients with an average follow-up of 5.3 years.31 The average interval from fracture to late reconstruction was 16.4 months, and 37 of 40 arthrodeses (92.5%) achieved initial union. There was a statistical trend toward a lower wound complication rate in the ORIF group and significantly higher outcome scores in the ORIF group. This suggests that initial restoration of calcaneal height, length, and overall shape is beneficial to outcome. In the event that the patient develops late post-traumatic arthritis, an in situ arthrodesis can be performed. 

Technique for Treatment of Calcaneal Malunion

Treatment is specific to malunion type: Type I malunions are treated a lateral wall exostectomy and a peroneal tenolysis; type II malunions are treated with a lateral wall exostectomy, a peroneal tenolysis, and a bone block subtalar arthrodesis, using the excised lateral wall as graft; and type III malunions are treated with a lateral wall exostectomy, a peroneal tenolysis, a subtalar arthrodesis, and a calcaneal osteotomy to correct hindfoot malalignment or shortening. 
The patient is placed in the lateral decubitus position, and a standard extensile lateral approach to the calcaneus is used. A lateral wall exostectomy is performed for all three malunion types (Fig. 61-51)169. Beginning posteriorly, the saw blade is angled slightly medially relative to the longitudinal axis of the calcaneus, leaving more residual bone plantarly, and thereby providing decompression of the subfibular region. Care is taken throughout the exostectomy to avoid violation of the talofibular joint. The exostectomy is continued to the level of the calcaneocuboid joint, and is completed with an osteotome, thus removing the fragment en bloc as a single piece for later use as a bone block autograft (Fig. 61-52). The peroneal tendon sheath is then incised over a length of 2 to 3 cm along the undersurface of the subperosteal flap and a tenolysis is performed. 
Figure 61-52
Calcaneal malunion fixation.
 
A: Lateral view demonstrating restoration of calcaneal height. Note bone block (white arrow). B: Broden view showing decompression of subfibular impingement. C: Axial view.
A: Lateral view demonstrating restoration of calcaneal height. Note bone block (white arrow). B: Broden view showing decompression of subfibular impingement. C: Axial view.
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Figure 61-52
Calcaneal malunion fixation.
A: Lateral view demonstrating restoration of calcaneal height. Note bone block (white arrow). B: Broden view showing decompression of subfibular impingement. C: Axial view.
A: Lateral view demonstrating restoration of calcaneal height. Note bone block (white arrow). B: Broden view showing decompression of subfibular impingement. C: Axial view.
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In patients with substantial subtalar arthrosis, (type II or III malunion)169 (Fig. 61-51), the subtalar joint is debrided of any remaining articular cartilage while preserving the underlying subchondral bone. The bony surfaces are prepared with a 2.5-mm drill bit, and the previously resected lateral wall fragment is then placed within the joint as an autograft bone block, with the widest portion of the autograft oriented posteromedially to avoid varus malalignment. With the subtalar joint held in neutral to slight valgus alignment, definitive stabilization is achieved with two large (6.5-, 7.3-, or 8.0-mm) partially threaded cannulated lag screws placed from posterior to anterior in diverging fashion into the talar dome and neck. A third screw may be added in the anterior process region extending into the talar neck and head (Fig. 61-52). In patients with a type III malunion, correction of angular malalignment within the calcaneal tuberosity is performed prior to implant placement: A Dwyer closing wedge osteotomy is performed for those with varus malalignment, while a medial displacement calcaneal osteotomy is used for those patients with valgus malalignment. Routine layered closure is completed over a deep drain. Weight bearing and early range-of-motion exercises are initiated for type I malunions once the incision has healed, whereas those with type II and III malunions are not permitted to weight bear for 12 weeks postoperatively, until radiographic union is confirmed. 

Ankle Pain

In the event of subtalar joint stiffness, inversion and eversion forces are borne by the ankle joint because of the coupled nature of the ankle and subtalar joint complex.158 The ankle joint, however, is not intended to bear these stresses, and the patient experiences lateral ankle pain. These sequelae are typically managed nonoperatively, using nonsteroidal anti-inflammatory medication, temporary immobilization, or the use of a lace-up ankle brace. In the authors’ experience, patients with recalcitrant pain may benefit from an arthroscopic debridement of intra-articular adhesions or chronic scarring that has developed during the immobilization period of fracture healing. 

Heel Pad Pain

Chronic heel pad pain may result from damage to the unique septated architecture of the heel pad. Sallick and Blum151 recommended sensory denervation for this problem, but their ability to distinguish various causes of pain was limited and they performed this procedure indiscriminately. Both Barnard and Odegard9 and Lance et al.92 recognized that plantar pain from a damaged heel pad is not improved by operative treatment. Currently, aside from use of a viscogel heel cushion, there remains no effective treatment for this problem. 

Heel Exostoses

Patients may develop painful plantar bony prominences following a calcaneal fracture. If nonoperative methods, such as heel pads, are unsuccessful, these painful exostoses can be removed surgically, as originally described by Cotton in 1921.33 A plantar incision should be avoided, as this is associated with painful scarring. 

Cutaneous Nerve Injury

The most common neurologic complication associated with operative management of calcaneal fractures is iatrogenic injury to a sensory cutaneous nerve. The sural nerve is the most common nerve involved because of the frequency of use of the lateral approach, and this complication may occur in up to 15% of cases.101 In this approach, the nerve may be injured at either the proximal or distal portions of the incision, and the injury may vary from a stretch neurapraxia, which may be transient or permanent, to a laceration of the nerve. Clinically, the patient may develop a partial or complete loss of sensation in the affected area or a painful neuroma. Nonoperative treatment is generally advised and may include pharmacologic management such as gabapentin or amitriptyline, physical therapy modalities, and soft accommodative shoe inserts or modifications. In the event of a painful neuroma that does not respond to nonoperative treatment, neurolysis or resection of the neuroma and stump burial into deep tissue or bone may be considered. 

Nerve Entrapment

Nerve entrapment is most common following nonoperative management of a calcaneal fracture and typically involves entrapment or compression of the posterior tibial nerve secondary to soft tissue scarring, a malunited fracture fragment, or bony exostosis causing impingement against the nerve.90,101,121 Patients experience medial-sided heel pain with associated paresthesias in the distribution of the posterior tibial nerve, and the pain is commonly worse at night or with activities, such as standing or walking. Clinically, there may be a positive Tinel sign along the course of the involved nerve. The diagnosis can be confirmed by injection of a local anesthetic in the tarsal tunnel or by electrodiagnostic studies. When clinical and diagnostic tests indicate nerve entrapment, surgical neurolysis and decompression of the posterior tibial nerve and its branches may be indicated. 

Author’s Preferred Method of Treatment in Calcaneus Fractures (Fig. 61-53)

Figure 61-53
Algorithm for Author’s Preferred Method for treatment of calcaneal fractures.
Rockwood-ch061-image053.png
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Summary, Controversies, and Future Directions in Calcaneus Fractures

The management of calcaneal fractures will continue to pose significant challenges to the orthopedic surgeon due to the complexities of the fracture patterns and the existing limitations in the soft tissue envelope. Although open reduction and internal fixation through the extensile lateral approach, when executed properly, remains the current gold standard for most displaced intra-articular calcaneal fractures, wound complications continue to be problematic in certain instances. It remains to be seen whether or not the limited incision or percutaneous approaches will prove to be efficacious long term with regard to functional outcome, wound complication rate, and the incidence of late post-traumatic subtalar arthritis. 

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