Management of Calcaneal Fractures PDF

Injury, Int. J. Care Injured 43 (2012) 1640–1650 Contents lists available at SciVerse ScienceDirect...

Injury, Int. J. Care Injured 43 (2012) 1640–1650 Contents lists available at SciVerse ScienceDirect Injury journal homepage: www.elsevier.com/locate/injury Review Management of calcaneal fractures What have we learnt over the years? Enrique Guerado *, Marı́a Luisa Bertrand, Juan Ramón Cano Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella, Malaga, Spain A R T I C L E I N F O A B S T R A C T Article history: Calcaneal fractures result, in many cases, in, subtalar joint stiffness and severe disability. Diagnosis is Accepted 7 May 2012 usually made by X-ray, but more accurately by a computed tomography (CT) scan. In the last years, much has been known regarding its physiopathology and osteosynthesis. Although new developments in Keywords: osteosynthesis materials have been made, calcaneus fractures still remains in dispute of those advocating Calcaneus fracture non-operative treatment and those defending open reduction and internal ﬁxation. Less invasive surgery, ORIF arthroscopy and three-dimensional (3D) ﬂuoroscopy are very important for reduction accuracy and soft- Arthroscopy tissue damage avoidance. In this article, the physiopathology, diagnosis, classiﬁcation and treatment of Arthrodesis Less invasive surgery calcaneus fractures are updated. Nevertheless, systematic reviews have shown no evidence about what Systematic review treatment is better. ß 2012 Elsevier Ltd. All rights reserved. Contents Introduction.................................................................................................... 1640 Diagnosis...................................................................................................... 1641 Clinical assessment......................................................................................... 1641 CT scan.................................................................................................. 1642 Fracture patterns........................................................................................... 1643 Fracture classiﬁcation....................................................................................... 1643 Treatment...................................................................................................... 1644 ORIF..................................................................................................... 1644 LIS...................................................................................................... 1646 Arthroscopy............................................................................................... 1646 Autografting versus bone substitutes........................................................................... 1646 Arthrodesis............................................................................................... 1646 Operative versus non-operative treatment............................................................................ 1647 Systematic reviews.............................................................................................. 1647 Conﬂict of interest statement...................................................................................... 1648 References..................................................................................................... 1648 Introduction digital X-rays and, particularly, computed tomography (CT) scan. However, although new developments in osteosynthesis materials Much has been known about the physiopathology of calcaneus have been made, calcaneus fractures still remain in dispute in terms fractures in the last years, thanks to the important contribution of of those advocating non-operative treatment and those defending open reduction and internal ﬁxation (ORIF). Although new knowledge and implant developments have made ORIF, together with less invasive surgery, achieve better results than before, * Corresponding author at: Department of Orthopaedic Surgery and Traumatol- subtalar joint stiffness still will result in the majority of the cases. ogy, Hospital Costa del Sol, Autovı́a A-7 Km.187, 29603 Marbella, Malaga, Spain. The anatomy of the calcaneus is very complex, as it has many Tel.: +34 951976224; fax: +34 951976222. E-mail address: [email protected] (E. Guerado). different joint axes in three-dimensional orientations (Fig. 1). 0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.05.011 [(Fig._1)TD$IG] [(Fig._2)TD$IG] E. Guerado et al. / Injury, Int. J. Care Injured 43 (2012) 1640–1650 1641 Fig. 2. Medial view of calcaneus. The sustentaculum tali holds the medial facet and is attached to the medial malleolous (dotted line) by the deltoid ligament (continuous lines). Therefore in a calcaneus fracture the sustentaculum, together with the medial facet, is commonly separated from the calcaneus body, remaning connected to the tibia bone by the deltoid ligament. Below the sustentaculum tali, the groove for the ﬂexor hallucis longus can be open and the tendon incarcerate within the fracture. Above the sustentaculum tali the tibialis posterioris neurovascular bundle can be damaged in case of sustentaculum tali fracture. a: tuberosity. b: anterior process. d: posterior subtalar joint. f: middle facet for calcaneus–talus neck joint. g: sustentaculum tali. h: groove for ﬂexor hallucis longus. m: medial cortex. skin for a safe operation include active exercises and compression devices for intermittent oedema pumping.5 Fig. 1. Posterior view of the calcaneus. The 3D anatomy can be seen with the axes X-rays. Radiological studies are the basis for a proper diagnosis, of the tuberosity, the anterior process, and the lateral and medial cortex in different and therefore a guide for treatment. There are two main directions. The subtalar joint has itself also different orientations. Although the radiological projections: lateral and axial views. calcaneocuboid facet cannot be seen in this view, it also has a different orientation. a: tuberosity. d: posterior subtalar joint. f: middle facet for calcaneus–talus neck 1. Lateral projection. There are also two important radiographic joint. g: sustentaculum tali. k: lateral cortex. m: medial cortex. landmarks on the lateral X-ray (Fig. 5). The posterior joint facet is convex, sloping posteromedially in [(Fig._3)TD$IG] its support of the talar body. The anterior and middle facets support the talar head and neck, and are ﬂattened. The medial facet is supported by the sustentaculum tali, a hard bone process very interesting to be considered for screw purchase in case of osteosynthesis (Figs. 2 and 3). A groove divides the posterior and the complex anterior– middle facets. This groove has the insertion of the interosseous ligament. The lateral part of the groove is the ﬂoor of the sinus tarsi (Figs. 3 and 4). As the posterior subtalar joints is responsible for most of the eversion-inversion movement, and during inversion the midfoot joints are locked for gait, three-dimensional reconstruction of the whole calcaneus becomes of overwhelming importance. Diagnosis Clinical assessment Fig. 3. Anterolateral view of the calcaneus. The interosseous ligament inserts itself Swelling and deformity are the main diagnostic symptoms and in the more medial part of the sinus tarsi. It separates the medial and anterior facets signs. Soft-tissue situation must be examined thoroughly to avoid from the sinus tarsi, making difﬁcult to access the sustentaculum tali from a lateral skin complications if surgical treatment is expected to be applied, surgical approach. Therefore these facets cannot be seen during a lateral extensile as skin necrosis has been published to occur in up to 43% of approach unless a part of this ligament is resected. The sinus tarsi are the lateral patients.1,2 Blisters commonly developed in displaced fractures. cavity formed in the lateral area of the tarsi groove (arrow). This groove separates the tuberosity from the anterior process, and the medial from the anterior facet. a: Clear-ﬂuid blisters indicate that a safe skin incision can be made, tuberosity. b: anterior process. c: calcaneocuboid joint. d: posterior subtalar joint. whereas blood-ﬁlled blisters indicate a major soft-tissue danger.3,4 e: sinus tarsi. f: middle facet for calcaneus–talus neck joint. f0 : anterior facet for Methods to improve oedema and accelerate the ‘wrinkle test’ of the calcaneus–talus head joint. i: interosseous ligament. k: lateral cortex. [(Fig._4)TD$IG] 1642 [(Fig._6)TD$IG] E. Guerado et al. / Injury, Int. J. Care Injured 43 (2012) 1640–1650 Fig. 4. View from above of the calcaneus. From above it can be seen the different orientation the three facets have. Also how the interosseous ligament impedes the access to the medial and anterior facets from a lateral approach, being the medial Fig. 6. CT-scan sagittal slice. A 33 year-old patient with a calcaneus fracture. Böhler wall of the sinus tarsi. The sinus tarsi – delineated by arrows – is the pathway to and Gissane’ angles are altered. A line separating the tuberosity apart from the rest approach the medial and the anterior facets provided the interosseous ligament is, of calcaneus body can be seen. at least, partially removed. n–n0 line illustrates the primary fracture line leaving the anteromedial fragment (‘‘constant fragment’’) containing the anterior and medial facets, the sustentaculum tali, and usually the very medial part of the posterior facet; laterally the posterolateral fragment contains the calcaneal tuberosity, the CT scan lateral wall, and the lateral part of the posterior facet. a: tuberosity. b: anterior process. c: calcaneocuboid joint. d: posterior subtalar joint. e: sinus tarsi. f: middle The CT scan is, up to now, the most important diagnosis tool for facet for calcaneus–talus neck joint. f0 : anterior facet for calcaneus–talus head joint. the study of calcaneus fractures6 and has deﬁnitely shown a strong g: sustentaculum tali. i: interosseous ligament. k: lateral cortex. m: medial cortex. association between the severity of the fracture and the depression n–n0 : primary fracture line. of the Böhler angle.7 All slices must be carefully observed. Axial slices give good information of the lateral wall, the calcaneocuboid Böhler’s angle assesses calcaneal height and joint depression joint and the sustentaculum tali. Sagittal slices permit evaluation and of anterior process and subtalar joint,8 and coronal slices allow Gissane’s angle is indicative of anterior, middle and posterior assessment of heel width, submalleolous impingement and facets’ relationship alteration. comminution and displacement of the subtalar joint, mainly the 2. Axial projection. This projection is useful for evaluating varus posterior facet (Figs. 6 and 7). Three-dimensional reconstruction of deformity of the calcaneus, widening of the heel, step-off in the the calcaneus allows a wonderful overall view of the fracture posterior facet and its relation with the sustentaculum tali. pattern; however, it minimises fracture lines and displacement; its However, a CT scan for this purpose is more reliable. usefulness is better achieved once the three planar slices have been [(Fig._7)TD$IG] studied (Fig. 8). [(Fig._5)TD$IG] Fig. 7. CT-scan coronal slices of the former patient. Intra-articular fracture of the calcaneus; the posterior joint has several step-off, the tuberosity appears Fig. 5. Lateral view of calcaneus. The talus is above the calcaneus, so that it can indemmne although into varus deviation and separated apart from the rest of hammer the ﬂoor of the sinus tarsi (arrow) provoking a calcaneus fracture. Böhler’s the calcaneus body. The sustentaculum tali, although fractured, remains attached to angle represents calcaneal height and joint depression. Its normal angle value is the medial malleolus so that the anterior and medial joints are not dislocated. The 258–408. Gissane’s angle is indicative of anterior, middle, and posterior facets lateral cortex is anterior and posteriorly well preserved whereas the medial one is relationship alteration. Its normal value is 1208–1458. a: tuberosity. b: anterior interrupted by a fracture line. a: tuberosity. d: posterior subtalar joint. e: sinus tarsi. process. c: calcaneocuboid joint. d: posterior subtalar joint. e: sinus tarsi. j: talus f: middle facet for calcaneus–talus neck joint. g: sustentaculum tali. j: talus process. process. k: lateral cortex. k: lateral cortex. m: medial cortex. [(Fig._8)TD$IG] E. Guerado et al. / Injury, Int. J. Care Injured 43 (2012) 1640–1650 1643 This fragment usually remains connected to the talus and medial malleolus thanks to the interosseous and deltoid ligaments, and is considered to be a ‘constant fragment’. 2. Posterolateral fragment. It holds the calcaneal tuberosity, lateral wall and part of the posterior facet. This fragment usually remains connected to the Achilles tendon, and is pulled by it into a varus position. Some authors have also hypothesised that there are two primary fracture lines. One runs from Gissane’s angle to the medial cortex, and another one to the anterior facet of the joint.10 Should the fracture affect also the calcaneocuboid joint, the prognosis is worse.11–14 Consequently, it is possible that several ‘primary lines’ occur. Many other fracture patterns may exist, such as the extrarticular tongue-type one (Fig. 14), resulting by Achilles tendon traction from the dorsal calcaneal tuberosity and posterior Fig. 8. 3D CT-scan of the former patient. (1) The posterior subtalar joint is ﬂattened with fracture lines in the lateral cortex (corresponds to diminution of Böhler’s angle facet, separating it from the rest of the calcaneus bone. If the lateral in the sagittal view); however a plate may be screwed in the well preserved anterior wall displaces itself, an impingement either with the lateral (anterior process) and posterior (tuberosity) areas of the lateral cortex. (2) The malleolus or by the time of shoe wearing may occur. Loss of medial cortex is fractured just below the sustentaculum tali, which keeps itself Böhler’s angle will result in a traumatic ﬂat foot. attached to the medial malleolous by the deltoid ligament, so that the medial joint (calcaneus–talus neck) is not dislocated; capsular attachment of this joint is also well preserved. (3) The tuberosity is deviated into varus position. These 3-D views Fracture classiﬁcation give very good information about the overall lesion, being very usueful for surgical plans. a: tuberosity. b: anterior process. e: sinus tarsi. g: sustentaculum tali. j: talus More than a few classiﬁcations have been developed during the process. k: lateral cortex. m: medial cortex. years, but essentially calcaneal fractures can be intra- or extra- articular. Extra-articular fractures affect either the anterior process Fracture patterns – very rarely – or, most commonly, the tuberosity. The original easy classiﬁcation by Essex-Lopresti into tongue-type and joint Precise fracture pattern analysis is one of the last pieces of depression has persisted over the years.9 Some other classiﬁcations knowledge obtained in calcaneus fractures. Intra-articular calca- such as Letournel’s,15 Sanders’,16 Arbeitsgemeinschaft für Osteo- neal fractures are generally provoked by a suddenly applied load to synthesefragen-Orthopaedic Trauma Association (AO-OTA)17 and the heel. The fracture pattern depends on the position of the foot the American Orthopaedic Foot and Ankle Society (AOFAS)’s18 have and the subtalar joint by the moment of the traumatism, its force limited inter-observer reliability and reproducibility.19,20 and the bone quality. The inferior midcoronal portion and the Sanders’ CT coronal slice-based prognostic classiﬁcation is lateral process of the talus hammer into Gissane’s angle (Fig. 5), as limited to the posterior face. According to this classiﬁcation, the classically described by Essex-Lopresti.9 There are many possibili- more comminution in the posterior facet, the worse the prognosis ties of fracture patterns; however, two major fragments are is. Sander’s classiﬁcation only considers CT coronal slices, missing generally identiﬁed: an anteromedial and a posterolateral some other projections for complexity. It does not consider fragment. These fragments are created and split apart by the displacement, osteocondral fractures and soft-tissue or tendon ‘primary fracture line’ (Figs. 4 and 9). entrapment. Nonetheless, Sanders’ classiﬁcation and Regazzoni’s21 have a better prognostic value than those others published so 1. Anteromedial fragment. It consists of the anterior and middle far.22,23 As a matter of fact, no classiﬁcation deals with a holistic facets, the sustentaculum tali and a part of the posterior facet. concept of the calcaneus, the tridimensional conﬁguration of the [(Fig._9)TD$IG] Fig. 9. Algorithm on the pathogenesis of calcaneus fracture. The lateral process of the talus (also shown in Fig. 5 by an arrow), hammers the ﬂoor of the sinus tarsi and provokes a ‘‘primary fracture line’’ separating apart two major fragments: the anteromedial and the posterolateral. See also Fig. 4 for ‘‘primary fracture line’’. 1644 E. Guerado et al. / Injury, Int. J. Care Injured 43 (2012) 1640–1650 three facet joints and the calcaneus body, the consideration of severe vascular disease and inability for treatment collaboration by extra-articular or intra-articular fractures being very handy, patients on drug abuse or alcoholism.31 together with the situation of Gissene’s and Böhler’s angles.9,24 Operative treatment (OT). Operative treatment (OT) includes external ﬁxation with or without mini-open reduction, less Treatment invasive osteosynthesis with or without arthrocopical reduction, and classic ORIF. Simple or three-dimensional (3D) ﬂuoroscopy Principles. The goals of treatment must be: joint restoration and, intra-operative use is very important during any treatment. particularly, calcaneus height, length and heel-width restitu- tion.7,25 Care must be taken in understanding the helicoidal torsion ORIF the calcaneus itself has in relating the tuberosity with the joints and the lateral and medial cortex.26 Failing in doing so may be the ORIF is the gold standard, and has its main indication in reason why although anatomic reduction of the subtalar joint complex displaced intra-articular fractures that cannot be reduced fracture is achieved, subtalar motion is not completely normal- by less invasive methods. By all means, ORIF is the best method of ised.27 achieving anatomic joint reduction and calcaneus morphology Therefore, the most important concept we have learnt during restoration; however, soft-tissue complications are proportionally the last years, concerning the management of calcaneus fractures, directed to the aggression magnitude of soft tissue and the reason is that the three-dimensional calcaneus anatomy must be fully why ORIF is not always accepted for every case, being usually restored during the treatment, rather than only addressing the performed when soft tissue has recovered from fracture trauma. reduction to the posterior facet joint or height, length or axis Three different approaches have been in use for ORIF: lateral restoration, although, as in any joint, more than 1–2 mm of approach, medial approach and combined lateral and medial articular surface displacement provokes overload in the remaining approach. cartilage with a subsequent arthritis28; abnormal anatomy of the calcaneus morphology also affects the support of the foot lateral - The lateral approach either short or extended (Fig. 10) allows full column, provokes lack of body weight accommodation and also reduction of the posterior subtalar joint, the posterolateral impairment of the lever arm for gait propulsion through the fragment and any anterolateral fragment; however, because the gastrocnemius and soleus muscles. As abnormal anatomy affects interosseous ligament acts as a barrier for the medial structures the three-dimensional orientation of the posterior, medial and access and the medial calcaneus anatomy, medial fragments such anterior joints, the ability to walk on uneven surfaces and shock as those containing the sustentaculum tali cannot be well absorption during gait is severely disturbed. reduced through a lateral approach, although it is extend- Valgus inclination stabilises the foot during gait, but varus ed.15,21,32 Besides that, as extended lateral approaches may also deformity after fracture facilitates distal talar subluxation, interfere further with skin vascularisation,33 a medial approach lateralisation of the heel fat pad, overload of the tibialis posterior addressed to reduce and ﬁx the sustentaculum tali and medial tendon and diminution of push-off efﬁciency during gait. Widen- fragments makes sense.34 ing of the heel impedes the lateral malleolus and shoe wearing, - The medial approach has been also broadly described.24,34,35 It making heel-width restitution very important; also, heel-height has the advantage of allowing direct reduction of the two major decrease (equinus deformity) greatly affects talar inclination with fragments of the primary fracture line, which are medial ankle impingement. Corrective osteotomies for varus malunion in structures. Direct access to the tibialis posterior neurovascular extra-articular cases may do well, whereas in intra-articular bundle, ﬂexor digitorum retinacula and ﬂexor hallucis longus is fractures they remain unknown.29,30 Anyhow, exact correction of very easy. The medial approach, however, lacks access to any deformity is a big challenge. postero- and anterolateral fragments. A very important issue in the treatment of calcaneus fracture is - Combined lateral and medial approaches are indicated whenever soft tissue. Current surgical approaches and osteosynthesis lateral and medial fragments need accurate reduction. Combined materials are addressed to deal with soft tissue. Less-invasive [(Fig._10)TD$IG] surgery (LIS), arthroscopy and plastic-surgery procedures deal with this problem, and it looks advisable to address treatment by means of these, whenever risk for skin damage exists. Non-operative treatment (NO). The above goals of treatment can hardly be achieved by non-operative treatment as closed reduction is very difﬁcult to be accomplished. Mainly, what the NO treatment presumes is pain relief and subtalar motion maintenance while avoiding potential skin complications. Swelling is better treated by a compression bandage in a 908 ankle ﬂexion splint to avoid equinus contracture. Early physiotherapy for full range of motion of all joints is started afterwards. After radiograph healing, occurring after some 8–12 weeks, weight bearing is progressively applied. Alternatively, custom-made casts can be applied since the beginning, to avoid heel widening and the common varus deformity. In some cases, a K wire with traction can be used while reduction manoeuvres are made. Heel widening can be corrected by applying lateral and medial compression. The value of closed reduction depends on the fracture patterns; in any case, anatomic reduction of articular compromise should not be expected. NO obtains good results in otherwise radiographically Fig. 10. Extended lateral surgical approach of the former patient. Direct access to the lateral cortex, sinus tarsi, and posterior subtalar joint is gained by retracting up very bad cases provided the heel allows a comfortable shoe wear, the sheath of the peroneal tendons (arrows) together with a full thickness skin ﬂap and has its main contraindication in old patients, severe smoking, in order to avoid skin ischaemia (according to Letournel (229), Regazzoni (326), and advanced diabetes mellitus, treatment with high doses of steroids, Benirschke et al. (30)). a: tuberosity. [(Fig._1)TD$IG] [(Fig._13)TD$IG] E. Guerado et al. / Injury, Int. J. Care Injured 43 (2012) 1640–1650 1645 Fig. 11. Perioperative ﬂuoroscopy of the former patient. After fracture reduction by holding up the posterior subtalar joint through the lateral cortex with a periostotome and a K wire, a lateral X-ray control is made before proceeding with grafting, and plate and screws insertion. Böhler’s and Gissane’s angles are restored. approaches are favoured by many authors.36–38 Small incisions in combined approaches address better for soft tissues with a less complication rate36,37 than those developed in the combined extensile approaches.38 In these open reductions, the skin blood supply must always be a concern.39,40 - Osteosynthesis in ORIF is accomplished once the subtalar joint and the three-dimensional anatomy of the whole calcaneus have been neatly reconstructed. Osteosynthesis takes advan- tage of K wires, lag screws and plates, including the new locking plate technology. K wires work very well, but only for provisional stabilisation during surgery (Figs. 10 and 11). Lag screws are usually used in combination with buttressing tricortical bone graft harvested from the iliac crest, and low proﬁle locking plates have been introduced with the intention of increasing osteosynthesis stability while interfering little with soft tissues (Figs. 12 and 13). A surgical technique of plating for calcaneus has been broadly published, but the Fig. 13. Perioperative ﬂuoroscopy of the former patient. AP X-ray projection to outcome of locking plates is, nonetheless, controversial as to check that no impingement exists between bone fragments, the plate and lateral whether locking plates behave better than the non-locking malleolous. ones.41–45 In the last years, bioabsorbable osteosynthesis materials show promising results but more studies are needed.46,47 [(Fig._12)TD$IG] What is capital in calcaneus fracture osteosynthesis is the knowledge by the surgeon of the internal anatomy of the calcaneus to ﬁx the screws into the bone safely and with good purchase48,49 as to provide adequate stability and maintenance of the reconstructed joint, deﬁnitely in a well-reconstructed, three- dimensional calcaneus anatomy, either with some large K-wires plus bone graft and an immobilisation with a plaster, a cast or, preferably, by a plate, either a compression plate or a locking one. In any case, soft-tissue preservation has to be a major issue and protruding materials have to be discarded, regardless. In relation with soft-tissue problems, the compartmental syndrome although very rare, affecting only the 10% of calcaneus fractures, may be a devastating complication50; prompt fasciect- omy is the indication. Open fractures, particularly those from blasting injuries, are very severe because of the covering soft-tissue damage51; they may easily end in a below-knee amputation.52,53 Open fractures in civil life need the same treatment as any other bone with debridement and antibiotic treatment; however, early Fig. 12. Perioperative ﬂuoroscopy of the former patient. Final lateral X-ray control after reduction and osteosynthesis, just before skin closing is made. A bone coverage by a free ﬂap is mandatory, and easier than in tricortical buttressing autograft from iliac crest can be seen (arrow). military injuries. [(Fig._14)TD$IG] 1646 E. Guerado et al. / Injury, Int. J. Care Injured 43 (2012) 1640–1650 Fig. 14. Extra-articular tongue-type fracture treated with percutaneous screws. (1) The tuberosity is extra-articularlly and longitudinally splitted in two parts. The proximal one is pulled up by the Achilles tendon, whereas the more distal one remains in place. In this fracture no soft tissue injury exists. Simple reduction and osteosynthesis will obtain good result. (2) Reduction by plantar ﬂexion of the foot and screwing with two cancellous bone screws with washers usually obtain good result. Washers are very important in order to apply compression with the two lag screws. LIS position provides a safe access, excellent visualisation of the posterior talocalcaneal facet and easy ﬁxation for posterior LISs try to avoid wound complications provoked by ORIF.39,54 screws.71 Conversely, articular reduction accuracy is worse achieved by LIS In some patients, a 3-portal (anterolaterally, centrally and than by ORIF. Many different reduction manoeuvres for LIS have posterolaterally) approach may be needed, to gain access to the been described in the literature.4,9,36,55–63 sinus tarsi, the lateral gutter and the posterior talocalcaneal facet. They combine traction by a K wire together with percutaneous Persistent pain with mild, degenerative changes of the subtalar pin manipulation of fragments and osteosynthesis by K wires, joint should also be considered an indication of arthroscopical cannulated screws or external ﬁxation. In relation to fracture debridement.72 Improvement in the movement of the subtalar patterns, LIS may be a good option for extra-articular fractures64; joint is usually achieved; however, patient satisfaction is not however, in more complex articular fractures full ORIF, if not guaranteed.73 Further, non-union an avulsion fractures can be contraindicated, may be necessary. successfully treated either by mini-open approach or by arthros- Since with non-operative treatment subtalar joint reduction copy,62,67,74 and also when a free ﬂap covers a signiﬁcant soft- and calcaneus morphology reconstruction is not possible, and tissue defect, arthroscopy minimises the free ﬂap damage.40,70 surgical treatment is associated with a high rate of complications, The short-term results of arthroscopical treatment of calcaneus LIS appears to be an option for accurate reduction and minimisa- fractures are excellent, while long-term results with greater tion of soft tissue complications in less severe fracture patterns. patient cohorts are unknown.57 Anyhow, arthroscopy for calcaneus Hence, LISs are indicated in patients who otherwise would have fractures has a steep learning curve, and in some instances only indication for non-operative treatment.31 New LIS techniques conversion to ORIF is necessary. have been developed with the help of arthroscopy57,65 or 3D images.61,66 Autografting versus bone substitutes Arthroscopy As the main feature of calcaneus fracture is subtalar joint depression with underlying bone crush, reconstruction by lifting Arthroscopy is one of the new tools in the current calcaneus bone fragments to joint restoration leaves an important cavity fracture treatment armamentarium aimed at achieving better (Fig. 11). This must be ﬁlled in a buttressing fashion by a tricortical reductions with reliable stabilisation, but without interfering with bone graft harvested from the iliac crest, by a tricortical allograft or soft-tissues physiology.67 Percutaneous arthroscopically assisted by another bone substitute. Discussion on the beneﬁt of these osteosynthesis allows accurate assessment of the articular surface procedures has been published in the last years.75,76The gold and supposedly anatomical reduction.57 Subtalar arthroscopy standard is a column of tricortical autograft buttressing the complements ﬂuoroscopy in anatomic reduction of the posterior subchondral bone of the subtalar joint accessed through the lateral calcaneal facet of the subtalar joint, particularly in Sanders type II cortex (Fig. 11). However, morbidity of autograft harvest from the and AO-OTA 83-C2 fractures.60 iliac crest or Gerdy’s tubercle has encouraged surgeons to use bone Another indication of arthroscopy after a calcaneus fracture is substitutes.77–82 the calcaneo-ﬁbular impingement syndrome when the space between the tip of the ﬁbula and the lateral wall of the calcaneus is Arthrodesis decreased. The abnormal bony and soft tissue can be removed by a 2-portal endoscopic technique. Subtalar release or fusion can be Subtalar arthrodesis can lead to degenerative changes in the added at the same time.68–70 This 2-portal approach in the prone ankle joint; however, this is the most effective method for the E. Guerado et al. / Injury, Int. J. Care Injured 43 (2012) 1640–1650 1647 treatment of residual pain, resulting in a high rate of patient shoes wearing when patients were treated by means of the surgical satisfaction.83 As stated above, arthrodesis can be easily and safely approach. These ﬁndings have been conﬁrmed by some others performed by arthroscopy particularly in the case of soft-tissue authors,1,102 but still methodology is an important burden for problems.70 reaching deﬁnitive conclusions. Primary subtalar arthrodesis may be the choice for the Although the tipping point for discussion is when to apply NO or treatment of markedly comminuted intra-articular Sanders type OT, as there are so many variables to be studied in relation to IV calcaneal fractures. Nevertheless, whereas some authors believe patient characteristics, fracture patterns and techniques, compari- that there is no need for a previous ORIF to restore the normal son between NO and OT is very difﬁcult.98 Bohler and Gissane angles, some others claim that better functional outcomes and fewer wound complications are associ- Systematic reviews ated when ORIF of a displaced intra-articular calcaneal fracture is ﬁrst performed; apparently, initial ORIF restores calcaneal shape, We have searched for the keywords ‘Calcaneus’ WITH alignment and height, which facilitates the fusion procedure and ‘Systematic Review’, ‘Clinical Trials’, ‘Cochrane’ and ‘Evidence establishes an opportunity to create a better, long-term, functional Based Medicine’. Databases used were MEDLINE, EMBASE, CINAHL, result.84 Still some other authors believe that the non-operative Google Scholar, the Cochrane Controlled Trials Register and the approach of Sanders type IV fractures may be simpler, less Cochrane Musculoskeletal Injuries Group Trials Register. There are expensive and with fewer complications than surgical treatment,85 a few evidence-based medicine or systematic review papers on even that comminuted medial fracture line in Sanders’ C sub-type calcaneus fractures. We found four recent papers dealing with might be a contraindication for surgery,86 lacking a correlation systematic reviews2,103–105; after reading them, we also followed between the severity of the fracture, the quality of the reduction the same searching strategy as they did, ﬁnding none apart from and the functional outcome.87 those four. One of these reviews was withdrawn by Cochrane As, usually, in any arthrodesis, the subtalar arthrodesis Collaboration itself in 2008 because of ‘‘out of date in terms of technique must combine a hardware system for bone ﬁxation evidence and methods’’.103 As these papers are consecutive, with together with a biological substance to enhance bone formation. A little time between them (2008–2011), and also accomplishing wide range of techniques has been described to achieve subtalar very few papers with not so many calcaneus fracture cases, the fusion. Minimally invasive surgery trying to minimise the risk of main ﬁndings are rather the same (Table 1). As also the existing malpositioning the screws has a lower rate of complications88,89 trials are of relatively poor quality, again little evidence can be either alone or arthroscopically assisted.71 As for calcaneus drawn from systematic reviews. fracture reduction and stabilisation, many biological substances Consequently, it is unclear if general health outcome measures, have also been used for subtalar joint arthrodesis. injury speciﬁc scores and radiographic parameters improve after Either as a primary operation or after reduction, subtalar operative management, and whether the beneﬁts of surgery distraction bone-block arthrodesis for malunited calcaneal frac- outweigh the risks.2,103,106 tures is usually necessary after 1–2 years follow-up. Although nonunion is very infrequent, normal alineation after malunion is very difﬁcult to be achieved; talocalcaneal height, talus-ﬁrst Table 1 Summary of conclusions by systematic reviews.2,104,105,109 metatarsal axis, talar declination angle and talocalcaneal angle, compared with the unaffected side, are very difﬁcultly to be Diagnosis2,104,105,109 Fracture pattern unspeciﬁed Treatment type2,104,105,109 More than 15 types and combinations restored, resulting usually in neighbourhood joints arthritis.90 Surgical timing2,104,105,109 Unknown or tailored to each clinical case Conversely, some authors believe that in the long-term follow-up Surgical approaches2,104,105,109 Several. Unknown which is better for subtalar arthrodesis does not show calcaneocuboid and talo- beneﬁt/risk. Speciﬁc on sinus tarsi navicular joints osteoarthritis signs, making triple arthrodesis unknown if better for beneﬁt/risk105 unnecessary,91 although the combination of ipsilateral talar ORIF2,104,105,109 Considered the gold standard Percutaneous reduction Less complications, but unknown if fractures with calcaneus fracture provokes subtalar arthritis and ﬁxation2,104,105,109 more effective regardless of the treatment applied92 and the needs for arthrodesis. Sinus tarsi approach105 Unclear if equal or better than Nonetheless, dynamic pedobarography may return to normal with extended lateral quite functional local load transfer, heel-height restoration being Treatment outcome2,104,105,109 No evidence if any superior to another Differences non-operative None on pain very important as the amount of correction of the heel height versus operative2 correlates with a normal pattern of pressure transfer on the Differences non-operative Better operative for return to work heel.90,93 versus operative2 Differences non-operative Better operative for wearing the Operative versus non-operative treatment versus operative2 same shoes Impulse compression Better subtalar motion, and return therapy2 to work Operative versus non-operative treatment has been a long- Complications2 Less in less invasive, but unknown what lasting discussion in the orthopaedic community. Many studies treatment is more effective support either treatment. However, when these papers have been Excellent/good Over 75% of cases (difﬁcult to know at results2,104,105,109 what time follow-up) studied in depth, methodology represent a burden for trusting Minor wound 0–15% (m = 4.1/4.8%) deﬁnite conclusions; also, stratiﬁcation of variables makes patient complications2,105 groups representation very difﬁcult. Infection105,109 m = 5.0%. 1.8% in centres operating > 1 The current trend point for surgical management is LIS. As case/month. 8.9 in centres problems of surgery are very much related to soft tissue, the operating < 1 case/month Secondary subtalar m = 4.3%/5.0%. 1.9% in centres percutaneous technique would minimise surgical complica- arthrodesis105,109 operating > 0.75 patients/month. tions.57,94–97 However, to our knowledge, no clinical trial has 6.4% in centres operating < 0.75 been published on the outcome of LIS. Instead, some randomised patients/month controlled trials have been published on classic ORIF.1,98–101 These Publish scores on 34 types outcome2,104,105,109 trials were summarised in the Cochrane database, where the Needs for regionalization109 Apparently evident authors have described better returned to their former job, and 1648 E. Guerado et al. / Injury, Int. J. Care Injured 43 (2012) 1640–1650 Large databases, although they do not ﬁt within ‘evidence based 13. Kinner B, Schieder S, Müller F, Pannek A, Roll C. Calcaneocuboid joint involve- ment in calcaneal fractures. Journal of Trauma 2010;68:1192–9. medicine’ give very useful information. The Canadian68 the 14. Miric A, Patterson BM. Pathoanatomy of intra-articular fractures of the calca- Dutch107 nationwide surveys, and also the Californian108 one, neus. Journal of Bone & Joint Surgery (American Volume) 1998;80:207–12. have shown, on the one hand that as operative management 15. Letournel E. Open treatment of acute calcaneal fractures. Clinical Orthopaedics and Related Research 1993;290:60–7. results in a lower rate of subtalar arthrodesis and a shorter time off 16. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 from work compared with non-operative treatment, operative displaced intra-articular calcaneal fractures. Results using a prognostic com- management is less costly and more effective.68 On the other, the puted tomography scan classiﬁcation. Clinical Orthopaedics and Related Re- search 1993;290:87–95. Dutch postal survey with nearly 1000 cases analysed that, 17. AO Foundation. http://www.aofoundation.org/Pages/home.aspx [accessed although percutaneous distraction reduction and ﬁxation appears March 2012]. to be a safe technique with overall good results and an acceptable 18. Zwipp H, Baumgart F, Cronier P, Jorda E, Klaue K, Sands AK, et al. 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