Management Intra-articular Fractures

Operative v Nonoperative Literature

 

1.  Buckley etal JBJS Am 2002

 

Prospective multi-centred RCT

- 309 displaced intra-articular fractures

- operative v non operative management

- 2 year follow up

 

Findings

- used patient orientated functional outcomes

- overall VAS and SF36 not significantly different between 2 groups

 

Improved Operative Outcome if

- not workers compensation

- women

- < 29

- bohler's angle 0 - 14 initially (not -56 to -1)

- light workload (not heavy manual worker)

- anatomical reduction < 2mm (CT of post facet)

- type 2 sanders (types 3 and 4 did not)

 

Note:

Any patient who required a subtalar arthrodesis to relieve pain was removed from the study.  

A non operatively treated patient was 5.5 x more likely to need this operation!

 

Complications  

- 5% deep infection

- 17% superficial infection

- STJ arthrodesis: non operative 17%, operative 3%

 

2.  Sanders 1993

 

Heel shape restored in 98+%

- Type II - 85% reduction and 75% good results

- Type III - 60% reduction and 70% good results

- Type IV - no anatomical reduction and 10% good results

 

Conclusion:

Sanders classification gives guide of prognosis

Once posterior facet is in more than 3 parts, good outcome decreases drastically

 

3.  Stulik etal JBJS Br 2006

 

287 displaced intra-articular fractures

- 1 year follow up

- Sanders 2, 3, 4

 

Any patient excluded from ORIF but amenable to OT

- DM / smokers / vascular insufficiency / compound wound / severe fracture blisters

 

Treatment

- MUA & Gissane spike percutanous reduction

- additional K wires

 

Results

- 16.5% excellent, 55.7% good

- 14.8% fair and 13% poor

- Sanders 2 > 4

 

Complications

- 1.7% deep infection

- 7% superficial infection

- nil amputation

 

Conclusion:  

There are intermediate options between ORIF and non operative

- with the ability to somewhat restore heel height and width

- in high risk patients who cannot have ORIF

- probably makes subsequent fusion easier

 

4.  Poeze et al JBJS Am 2008

 

Calcaneal volume load v outcome

- centres with higher volume load

- reduced rates of deep infection and subsequent subtalar arthrodesis

 

5.  Heller JBJS Am 2003

 

43 compound calcaneal fractures

- wound usually medial

 

Type I ORIF

- no infections in 7/7

 

Type II 

- 3/8 infection

 

Type IIIA

- 3/12 infection

 

Type IIIB

- 10 /13 infection 

- 6 /13 became deep osteomyelitis

- 3 required amputation

 

Conclusion

- very dangerous to ORIF anything other than Type I compound fracture

- a quarter to a third of type II and IIIA will get a deep infection

- absolutely not in any patient who will need a flap

 

6.  Folk et al JOT 1999

 

If patient had DM + PVD + smoker, wound problem rates > 90%

 

5. Rodger Atkins AOA 2000

 

Salvage arthrodesis very difficult

- always better to attempt reconstruction initially even if just to make arthrodesis easier

- alternative is Primary Arthrodesis

 

6.  Wei et al. Medicine 2017

 

Meta-analyis of operative v non operative for displaced intra-articular fractures

- 8 RCTs, 10 controlled trials, 1467 patients

- 4 studies used AFOS outcome measure, with no difference

- no significant difference in pain or shoe wearing

- operative group more likely to return to work

- complication rate of 26% in the operative group, significanlty higher

 

https://pubmed.ncbi.nlm.nih.gov/29245290/

 

 

Management

 

Aims

 

Pain free functional foot that can fit in a shoe

 

Goals

 

1.  Restore heel shape (height, length and width)

2.  Reduce joint surface

 

Options

 

1. Non-operative

2. ORIF

3. Primary STJ arthrodesis

4. Salvage / STJ arthrodesis

 

Issues

 

1.  Patient factors

 

Smoking 

- higher incidence infection

- try to get them to stop

 

DM, PVD

- high risk of infection

 

Heavy manual workers 

- will find it difficult to return to work

 

Bilateral fractures

- do worse

 

Gender

- women do better

 

Age

- younger do best

 

2.  Soft tissue envelope

 

Compound fractures

- wound medial

- operative for Type 1

 

3.  Fracture type

 

Bohler's angle

- if less than 0o initially, do poorly however managed

 

Sander's

- prognostic (type I do well, type IV high rates fusion)

- lateral wall fragments easier to fix (2A)

- very medial fractures (2C) very difficult

 

Assess

- Bohler's angle

- Posterior facet / Sanders

- CCJ joint

- lateral wall fragment

- sustentaculum fragment

- tuberosity / heel in valgus

 

4.  Surgeons experience

 

Non Operative Management

 

Indications

- non displaced

- Bohler's > 20

- Sanders IV

- DM, PVD

- compound fracture Type 2 & 3 

 

Technique

- elevate +++

- POP

- NWB 6/52

- Then progressive WB

 

Complications

- STJ OA

- peroneal impingement or subluxation

- calcaneocuboid arthritis

- malunion of hindfoot

- posterior tibial nerve entrapment

- difficulty with show wear

 

Operative

 

Indications

- healthy patient

- ? smoking

- Saunders II / III

- Bohler's < 20o

- displaced tongue type fractures

 

Contra-Indications

- severely comminuted sustentaculum tali

- type IV

 

Needs to be an individualised approach with risk stratification

 

Initial

- Bed rest, elevation, ice & compression till skin wrinkles evident

- between 1 week and 4 weeks

 

Blisters

- clear fluid (some epidermis attached to dermis)

- bloody fluid (no epidermis attached to dermis)

- shown that there is some increased risk of wound problems if incision passes through blisters

 

1.  ORIF  

 

Calcaneal ORIFCalcaneal ORIF LateralCalcaneal ORIF Axial

 

Technique

 

Position

- patient on side, blankets under foot

- operated foot up

- radiolucent table, II available

- GA, IV Abx, tourniquet

 

Incision

- extensile lateral approach

- behind posterior edge of fibula

- anterior to T Achilles

- sural nerve posteriorly in flap

- along borders of calcaneum (Abd H below)

- keep distal cut along inferior margin calcaneum

- angle up towards CCJ

 

Superficial dissection

- elevate full thickness flap with peroneal tendons

- down to bone

- divide CFL

- K wires to retract skin flap

- 2 in talus / 1 in fibula

- expose CCJ

 

Bleeding

- calcaneal artery

- branch of peroneal artery

 

Steinmann pin to tuberosity 

- through heel skin

- can elevate and pull out of varus

 

Hinge lateral wall fragment 

- opens on posterior / inferior periosteum

- gives access to subtalar joint

- if type 2C may need lateral wall osteotomy

- divide interosseous ligament 

- homan or lamina spreader to expose STJ

 

ORIF

- Reduce medial fragments and work laterally

 

1. Restore posterior facet with screws

2. Restore calcaneum height and Bohler's by reducing tuberosity fragment

3. Pull out of varus

4.  Reduce posterior facet & lateral joint fragment onto sustentaculum fragment

- golden screw

- 3.5 mm screw

- aimed anteriorly, medially and slightly upwards

5.  Elevate anterior process fragment

6.  Locking contoured plate

 

Intra-operative II

- lateral

- Broden's view

 

Closure

- careful haemostasis

- closure over drain

- elevate +++ for one week

 

Post op

- NWB 12 weeks

- early ROM exercises once wound healed (2-4 weeks)

 

2.  Essex-Lopresti closed reduction and percutaneous pinning 

 

Indications

- tongue type fractures 

- joint depression fractures not suitable for ORIF

- compound fractures

 

A.  Technique 1 for IA Fractures

 

Position

- patient prone with knee flexed

 

1st steinmann pin (if comminuted IA)

- from medial to lateral through body

- traction to restore height

- correct varus

- manually compress heel to reduce lateral wall displacement

 

2nd steinmann pin

- Posteromedial corner of posterior tuberosity

- aim towards sole and towards CCJ

- under thalamic portion, then lever pin dorsally

- aiming to correct Bohler's

- then aim towards CCJ and can even pass through

 

Incorporate 2 pins into plaster

- remove after 6 weeks

 

B.  Technique 2 Stulik et al JBJS Br 2006 for IA Fractures

 

Calcaneal Fracture Percutaneous Pinning

 

Transverse Steinmann as above

- disimpact fragments

- pull out of varus

 

Plantar stab incision

- posterior facet elevated with bone punch

 

Longitudinal Steinmann pins x 2

- elevate and hold thalamic portion

 

Transverse K wires under posterior facet

 

Results

- 1.7% deep infection

- 7% superficial infection

 

C.  Technique 3 for IA fractures

 

Percutaneous screws + Ilizarov

 

D.  Technique 4 Stulik et al for tongue type

 

Reduce tongue with longitudinal Steinmann

 

Fix with 2 mm K wire / screws

 

Calcaneal Fracture Tongue TypeCalcaneum Fracture Tongue Type ORIF

 

3.  STJ Arthrodesis

 

Indications

- type IV Sanders

- late STJ OA

 

Early

- ORIF with lateral plate

- 2 x 6.5 mm screws

 

Late

- In setting on previous fracture very difficult

- Still have to restore anatomy

- restore heel height & width 

- may have skin problems if have very planovalgus foot

- may need lateral bone block

- need lateral wall ostectomy

 

Calcaneal Fracture OA FusionCalcaneal Fracture OA Post Fusion