Address for Correspondence:
Ofir Chechik, MD
Department of Orthopedic Surgery
Tel Aviv Sourasky Medical Center
6 Weizman Street, Tel Aviv 64239, Israel
Phone: +972-3-6974727
Fax: +972-3-5477597
Email: ofirchik@yahoo.com
Abstract:
Introduction The calcaneus is the most frequently fractured tarsal bone. Treatment is either conservative or surgical, and there are many post-fracture complications. This study evaluated the short- and medium-term functional outcomes and complications of calcaneal fractures.
Methods The 47 study patients (49 calcaneus fractures) included 36 males and 11 females, mean age 49±14.5 years, mean follow-up 23±16 months. Functional outcome was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) score. Pain was measured on a visual analog scale (VAS).
Results Thirty-one (66%) patients underwent surgery and 16 (34%) were treated conservatively. Twenty-one operated patients (68%) had complications compared to one (6%) conservatively treated patient (infection). 11 (35%) operated and 12 (75%) non-operated patients had good-to-excellent outcomes (p < 0.005). The mean AOFAS score was 74±22.6 (range 15-100). VAS pain was 1.6±2.3 at rest and 5.7±3.5 during exercise. Poor outcome was associated with complications and being qualified for worker's compensation (p < 0.05). Range of motion in the injured foot was significantly decreased compared with the unaffected foot (ankle plantar flexion 40.1 degrees versus 45.7, p < 0.05; ankle dorsiflexion 10.4 degrees versus 14 degrees, p < 0.05; subtalar inversion 7.2 degrees versus 17.8 degrees, p < 0.0001; subtalar eversion 3.4 degrees versus 8.3, p < 0.0001, respectively).
Conclusion Calcaneus fractures cause severe injury. The short- and medium-term functional outcomes are generally unsatisfactory, with persistent pain and decreased range of motion. Surgery of displaced intraarticular fractures via the lateral approach is associated with especially high complication rates.
J.Orthopaedics 2011;8(4)e12
Keywords:
calcaneus fracture ;lateral approach ;complication.
Introduction:
Fractures of the calcaneal bone account for about 2% of all fractures and are the most common fracture in the foot [1]. They are sustained mostly in young active males, and are often associated with other injuries and poor functional outcome, resulting in a serious socioeconomic impact [1, 2]. Treatment options include either nonoperative treatment with non-weight bearing (mostly for non-displaced, extraarticular or anterior process fractures) or surgery [3]. Operative treatment is recommended for comminuted, displaced, and intraarticular fractures with the aim of preventing malunion, loss of normal anatomy, posttraumatic arthritis, widening and flattening of the foot, heel varus and peroneal tendon impingement [2]. An intraarticular 2-mm step as well as marked heel varus/valgus are considered indications for either open or closed reduction. Surgery can usually yield good results in 60-90% of cases, with anatomic reduction being a predictor of good outcome. However, surgery is also associated with complications, including sural (lateral approach) or tibialis posterior nerve (medial approach) lesions, wound necrosis and breakdown, infection and hematoma [2, 4].
The purpose of this investigation was to estimate and compare the short- and medium-term functional outcomes as well as the complication rates associated with conservative and surgical treatment of calcaneal fractures.
Material and Methods :
Between January 2006 and June 2010, 148 patients who sustained calcaneal fractures were treated in a single trauma center. All patients were invited to undergo an interview, physical examination and functional evaluation. The physical examination included measurements of heel height and width in comparison to the contralateral foot, motor and sensory examination, evaluation of the scar of operated patients, and the presence of peroneal or metatarsal tenderness. Function was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) [5] score, and subjective pain at rest and during exercise was measured on a visual analog scale (VAS, 0 no pain, 10 severe pain). Each patient's medical history, associated injuries, mechanism of injury, type and laterality of the fracture, fracture classification (Sanders) [6], post-surgical and general complications (delayed wound healing, superficial and deep infection, sural nerve injury, hindfoot malalignment, tenderness over peroneal tendons, painful plate and screws), current working status, recreational sport status and being qualified to receive worker's compensation were retrieved from their medical charts and verified during the interview conducted for the current study.
Conservative treatment included non-weight bearing for 6 weeks followed by gradual weight bearing and range of motion exercises. Surgical treatment of intraarticular fractures (>2 mm displacement as demonstrated on computerized tomography) was performed through a lateral L-shape incision, with direct under vision reconstruction of the posterior calcaneal facet and fixation with an AO calcaneal plate and screws (Synthes, Welwyn Garden City, UK) under the guidance of an image intensifier. Displaced extraarticular fractures were treated percutaneously for restoration of the anatomic Bohler and Gissane angles and fixation of the calcaneal tuberosity with two longitudinal screws. Partial weight bearing was began on the seventh postoperative week and progressed to full weight bearing after six additional weeks.
Descriptive analyses and specific statistical assessments were done by SPSS (17th version for Windows). A linear regression using the total AOFAS score as the dependent variable was performed to identify predictors of poor functional outcome. Significance was set at p < 0.05.
Results :
Of the 148 cases in the database, 63 patients were lost to follow-up, leaving 85 patients available for evaluation, of whom 47 agreed to participate. The final cohort comprised 36 males (37 fractures) and 11 females (12 fractures), whose mean age was 49±14.5 (18-75) years. The mean follow-up for the study group was 23±16 (4-60) months. Thirty-one patients underwent surgery and 16 were treated conservatively. All the study patients signed an informed consent form approved by the IRB and were interviewed and examined for this study.
The majority of the fractures (37/49) were caused by a fall from height, five were due to accidents, three were from direct trauma to the leg and four were from miscellaneous injuries. Twenty-one patients had simultaneously sustained injuries to other body parts. Ten patients had Saunders 1 fractures (extraarticular), 10 had Saunders 2, nine had Saunders 3, and 16 had Saunders 4. Four other fractures could not be classified because imaging scans were not available. Two patients had sustained bilateral calcaneal fractures.
The complication rate was significantly higher among the surgical patients compared to the non-surgical patients (p < 0.05) . One of the 16 patients (6%) who were treated conservatively had a superficial skin infection, successfully treated with antibiotics. Twenty-one of the 31 (68%) patients who were treated surgically had complications that included severe post-traumatic arthritis (treated with subtalar arthrodesis, n = 2), painful plate and screws (treated with removal of the metal implants n = 5), infection and wound breakdown (one surgically debrided, two treated with vacuum assisted closure and the others treated with antibiotics only, n = 10), sural nerve neuropathy (n = 4), and lateral heel pain over the peroneal tendon and/or plate/screws (n = 6). One of the operated patients also had a pulmonary embolism two weeks following his operation and was admitted to the intensive care unit.
The functional outcome was excellent (AOFAS score of 90-100) in 14 (30%) patients, good (80-89) in nine (19%), fair (70-79) in eight (17%) and poor (≤69) in 16 (34%). The mean AOFAS score for the entire cohort was 74±22.6 (range 15-100) (Table 1). The mean VAS score for pain was 1.6±2.3 at rest and increased to 5.7±3.5 during exercise.
The linear regression showed that the diagnosis of any complication and being found qualified to receive worker's compensation significantly associated with a worse functional outcome. Twenty-three patients (49%) returned to their previous occupation, five (11%) changed their occupation and 19 (40%) were unemployed at the time of last follow-up. Twenty-six patients had filed a workers compensation claim that was recognized by the authorities.
Eight patients had persistent severe foot edema and three patients had metatarsalgia. Leg measurements showed that mean calf circumference was decreased by 9±12 mm compared to the opposite leg , the heel was 3.2±3.4 mm wider and 5.6±5.8 mm shorter compared to the contralateral foot and range of motion was significantly decreased compared with the opposite foot (ankle plantar flexion 40.1 degrees compared to 45.7, p < 0.05; ankle dorsiflexion 10.4 degrees compared to 14 degrees, p < 0.05; subtalar inversion 7.2 degrees compared to 17.8 degrees, p < 0.0001; and subtalar eversion 3.4 degrees compared to 8.3 degrees, p < 0.0001).
Discussion :
We evaluated the functional outcome and the short- and medium-term complications following calcaneal fractures in a medium level trauma center (2.7 fractures treated per month). According to the values reported in the literature, good/excellent results can generally be expected in only 60-90% of patients with calcaneal fractures, even with optimal surgical care [1, 2, 4, 7]. Our results showed a rate of only 49% good/excellent results among these patients and only 60% of them returned to their original or another type of work. It has been reported that predictors of a favorable outcome include patient characteristics (i.e., young females, sedentary workers), fracture factors (initial Bohler angle of 15-36 degrees, extraarticular fractures, no contralateral foot injury, no polytrauma), and treatment factors (no arthrodesis, no complications, not receiving worker’s compensation and anatomic reduction [1, 4, 8, 9]. Only the development of complications and being awarded worker's compensation emerged as significant poor prognostic factors in our current work, although the small size of the cohort may limit the ability to detect other differences. In our view, being awarded worker's compensation for the injury should be considered associated with poor functional results rather than serving as a prognostic factor. Those patients are recognized as having lost their ability to be gainfully employed in their former occupation and are deemed qualified for financial assistance.
Reports in the literature describe numerous complications of calcaneal fractures, among them subtalar arthritis (10-28%), subtalar arthrodesis (3-17%), superficial (2-22%) and deep (1-2%) infections, wound healing problems (6-27%), complex regional pain syndrome (6%), sural nerve lesions (3%), smashed heel pad syndrome (6%), peroneal tendon discomfort (37%), deep vein thrombosis (0.5%) and pain related to plates/screws (20%) [1, 4, 8-11]. Reoperations are reported in 1-43% of the patients [4, 8]. The highest rates of wound complications were seen in smokers, leading some authors to consider smoking as being a contraindication for surgery [9]. Wound complications were also more common with delayed surgical treatment [11] and with treatment taking place in smaller institutes [12]. Our cohort presented 29 complications affecting 22 (47%) of the patients: 19 were directly related to surgical treatment using the lateral approach (need to remove metal implants, infections, delayed wound closures, sural nerve neuropathy). The complication rate among our operated patients reached a rate of 68%. Harvey et al. reported a 16.5% rate of complications among operated calcaneal fractures, but they did not consider another 43.5% of their patients who underwent plate removal or other secondary surgical interventions [10]. Alternatively, calcaneal fractures can be operated via a limited lateral or a sinus tarsi approach, possibly leading to fewer complications [13]. We identified four (12.5% of the operated feet) cases of sural nerve neuropathy during our examinations. This represents a much higher rate than the 3% previously reported in the literature on patients who were operated with the lateral approach [1]. Those lesions resulted in total or partial loss of sensation in the territory of the sural nerve. None of these lesions had been reported by the patients earlier nor were they recorded in their medical charts. We believe that unless the patients are specifically queried, such mild lesions may be underestimated and under-reported.
Our literature search yielded no previous reports on the precise decrease in range of motion, or extent of edema, cuff muscle atrophy and flattening and widening of the heel. Our results suggest that even with surgical treatment, the heel will widen and flatten following calcaneal fracture and that the range of motion will decrease significantly both in the ankle and the subtalar joints.
We are aware that this study is based on a small retrospective cohort with a variety of fracture patterns and treatments. As such, there is a high risk for selection bias, and the ability to conduct statistical analyses is limited. However, our data provide some additional information on the likelihood of a poor outcome whether these injuries are treated surgically or conservatively..We conclude that a calcaneus fracture is a severe injury. The short- and medium-term functional outcomes of such injury are generally unsatisfactory and are characterized by persistent pain, decreased range of motion and flattening and widening of the heel. Surgical treatment of displaced intraarticular fractures via the lateral approach may improve joint congruency and prevent the need for arthrodesis, but it is associated with high complication rates.
Reference :
- Aktuglu K, Aydogan U (2002) The functional outcome of displaced intra-articular calcaneal fractures: a comparison between isolated cases and polytrauma patients. Foot Ankle Int 23(4):314-318
- Rammelt S, Zwipp H (2004) Calcaneus fractures: facts, controversies and recent developments. Injury 35(5):443-461
- Schepers T, Ginai AZ, Van Lieshout EM, Patka P (2008) Demographics of extra-articular calcaneal fractures: including a review of the literature on treatment and outcome. Arch Orthop Trauma Surg 128(10):1099-1106
- Kurozumi T, Jinno Y, Sato T, Inoue H, Aitani T, Okuda K (2003) Open reduction for intra-articular calcaneal fractures: evaluation using computed tomography. Foot Ankle Int 24(12):942-948
- Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M (1994) Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 15:349-353
- Sanders R (2000) Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 82(2):225-250
- Ibrahim T, Rowsell M, Rennie W, Brown AR, Taylor GJ, Gregg PJ (2007) Displaced intra-articular calcaneal fractures: 15-year follow-up of a randomised controlled trial of conservative versus operative treatment. Injury 38(7):848-855
- Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R (2002) Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 84-A(10):1733-1744
- Buckley RE, Tough S (2004) Displaced intra-articular calcaneal fractures. J Am Acad Orthop Surg 12(3):172-178
- Harvey EJ, Grujic L, Early JS, Benirschke SK, Sangeorzan BJ (2001) Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach. Foot Ankle Int 22(11):868-873
-
- Tennent TD, Calder PR, Salisbury RD, Allen PW, Eastwood DM (2001) The operative management of displaced intra-articular fractures of the calcaneum: a two-centre study using a defined protocol. Injury 32(6):491-496
- Poeze M, Verbruggen JP, Brink PR (2008) The relationship between the outcome of operatively treated calcaneal fractures and institutional fracture load. A systematic review of the literature. J Bone Joint Surg Am 90(5):1013-1021.
- Schepers T. (2011) The sinus tarsi approach in displaced intra-articular calcaneal fractures: a systemic review. Int Orthop. 35:697-703
|
