Treatment Options

• Cast without reduction – doesn’t address joint incongruity or deformity in shape of calcaneus
• Cast with closed reduction
  • Bohler – took pin and placed medial to lateral through tibia
    • Took another steinman pin an put medial to lateral through calcaneus
    • Distracted to help reduce fracture to regain height, pulls calcaneus out of varus
    • Used Bohler’s clamp – vice to help decrease width of calcaneus, applied medial to lateral to compress calcaneus
    • Can cause soft tissue damage (nerve entrapments)
  • Gissane  - more common
    • Gissane spike – similar to steinman pin
    • Placed spike from posterior to anterior through tuberosity and into the posterior facet fragment
    • Pt prone with knee bent at 90 degrees then lifted leg off table to reduce fracture
    • Forces posterior facet back up against talus and realigns calcaneus
    • Casts around pin to maintain alignment
• Slipper cast modification – maintain STJ ROM for better healing – Essex-Lopresti modification
• Primary arthrodesis – usually triple according to literature
  • Only fuse affected joint unless several joints involved
  • May be able to just STJ fusion
  • If CC joint and posterior facet involvement – then do triple
  • If pt has multiple comminutions then may want to primarily arthrodesis
• ORIF – treatment of choice for displaced intra-articular fracture
• Techniques for repairing fractures are basically hybrids of 3 techniques:
  • Essex Lopresti technique
  • McReynolds technique
  • Palmer technique

 

Open vs Closed Indications

1. Age
   • chronological age may have no bearing on calcaneal fracture repair
   • physiological age, activity level, goals and expectations are more important determinants
   • osteoporosis is not a contraindication for fx fixation
2. Health status
   • is patient surgical candidate, can they be NWB for 2-4 months, can they go through required rehab
   • average intra-articular calcaneal fracture requires 1-2 years to get back to normal baseline activity
3. Activity level
   • what was the patient activity level before the injury
4. Occupation
   • take into consideration pts who work on there feet a lot
   • prolonged recovery, but good outcome
   • average intra-articular calcaneal fracture requires 1-2 years to get back to normal baseline activity
5.  Intra-articular
   • is there articular damage
6. Comminution
   • fusion usually required if there is severe comminution

 

• Good Clinical Outcome with ORIF
  • Sangers – 73/70%
  • Laughin – 78%
  • Burdeax – 80.3%
  • Thordarson – 80%
  • Crosby – 47% - just did closed reduction

 

Goal of Reconstruction

1. articular congruity reestablishment
2. restore height and width of calcaneus
3. allow early ROM otherwise there will be early increased risk of DJD, ankylosis, and stiffness