Treatment Calcaneus

liv KEAItNS

of Comminuted by Primary
It. THOMPSON,
LEXINGTON,

Fractures Triple Arthrodesis

M. FRIESEN,

of the

M.D.,

AND

CARL

M.D.,

KENTUCKY

Theie
fractures are

are

many
frequent

these
outcoimme. arthro(Iesis
a

fractures
()tme iii

there
of us

1048,

the calcaimeus, but conuninuted disability. In the treatment of and general pessimism as to the (K.H.T.) begaim treating these fractures by primary triple aimd it Imas been our (4xpetieimce that this procedure produces
varieties

of fractures of produce the greatest is much clifferetmce of opinion

and

iiigim

)ercentage

of satisfactory

results.
ANATOMY

r1i

calcaimeus, talus the

\ViliCil

is

tiit

largest
time

1)01-ic

in

time foot,

ttiticultttes

superiorly

cuboid. Timere are three superior articular and time anterior (Fig. 1-A). Fime posterior articular surface is tlonie simaped, is i iicli imed obliquely forward at approximately 45 degrees to the bug axis of the body, and is the largest of these articular areas. rfIlc elongated i-imedial atticular surface is usually divided into two parts by a imotch. The area posterior to the notch at-id lying anterior to the posterior articular surface is tie middle articular surface; it is supported by the sustentaculum tali. The area anterior to the posterior articular surface and lateral to the middle articular surface is the calcaneal sulcus; it forms the inferior half of the sinus tarsi. The posterior portion of the calcaneus is the tuberosity, whereas the anterior projection forms the cuboid articular surface. Superior and medial to the cuhoid articu-iith the with
surfaces:

posterior,

aim(1 anteiiorlv the

middle,

lar

surface,

hone

pronmitmence

is

evident,

which

is

called

the

anterior

process.

Middle articular surface

Anterior articular Ebsterior articular LTrochlear surface surface process
artic. surface

process

Cuboid Sustentaculum tall

)

t
Tuberosity-

Lateral
FIG.

process

1-A

Superior
*

and
of

lateral The

projections American

of the calcaneus. Academy of Orthopaedic Surgeons, Chicago,

Read

at

time

Annual

Meeting

Illinois,
VOL. 41-A,

January
NO.

27, 1959.
8, DECEMBER
1959

1423

1424

K.

R.

THOMPSON

AND

C.

M.

FRIESEN

A.

Normal

tuber-joint

angle

Lateral

Medial
B.

B.
Fm. 1-13
of time calcaimeus.

Ceiling

line Fi.. 2
ceiling line.

Inferior The and

l)rojectiorm

1)rawing

of the

cuboid
convex

articular
in a

surface
direction at

is concave
right aimgles

from
to

above
this.
As

dovnvard
has been

and

lateralward

out by Shephard, the coimfigurations of the articular surfaces of the joitmt, of the ball-and-socket talonavicular joint, at-id of the sui)talar joint allow medial and lateral motions of the foot. fh calcatmeus, whemi visualized from below (Fig. 1-B), exhibits a lateral bowimmg, or convexity, atmd a inetlial concavity.
1WENTGENOGRAPHI( EVALIATI0N

pointed (alcaneocuboid

As far back as 1720 (according to Goff), Garat-igeot described the smashed fracture. With the discovery of roentgen rays in 1895, Desfosscs offered the first accurate interpretation of the fractured calcaneus. In 1908 Cotton aid Wilson described their manipulative technique for treatment of this fracture, based on roentgenographic interpretatioim. Most investigators during the past fifty years have recommended that the roentgenographic diagnostic survey of a patient with a I)aitmftll heel after iimjury should include an anteroposterior projection of

FIG.

3
roentgenogram of time ankle,
and
showing

FIG.
fracture

4
of

Fig.
ture

3: Aiiteroposterior
3

the

calcaneus,

with

lateral sI)read. Fig. 4: Case

of time entire

(Table
body,

II). Lateral
involving

roentgenogram time subtalar

of time caleammeus, showing calcaneocuboid joiimts.

THE JOURNAL OF BONE

:m (olmmnmiimuted

frac-

AND

JOiNT

SURGERY

COMMINUTED

FRACTURES

OF

THE

CALCANEUS

1425

Fig. Fig.
fracture

5-A
I ). Lateral roentgenogram of time (alcaneus,

Fig.

5-B
a severe depression

5-A
of

: Case

9 (Table

simowing

the Posterior articular surface as well as time anterosuperior articular surface, with avulsion fractures of time posterior aspect of the talus and of the eui)oid. Fig. 5-B: Case 9 (Table I). Postoperative lateral roentgenogram after triple arthrodesis in which
two
t

staples

were

utilized

for

internal

fixation,

showing

restoration

of the

trai)ecular

p:mtterim

across

he artimrodesed

joitmts

time atmkle, a lateral lrujetioim ptojectioii of the calcatmeus. although l)leviOtlslY described,
jection of the calcaneus

of

time ankle

and

calcatmeus,

atid

aim

axial

( l)lalitar)

1rolmi
and

our

experience

we

believe

projections are an anteroposterior

necessary: projection

that two additiotmal, a lateral-oblique proof the mid-tarsal

j oitmts.
as

In tile anteroposterior projection of the ankle joint, injuries of the ankle, well as lateral spreading of the calcaneus (Fig. 3), can be detected. In addition to visualizing ti-ic fracture lines, the lateral projection permits the evaluation of the tuber-joint angle of B#{246}hler(Figs. 4, 5-A, arid (3-A), as well as the ceiling line described byG. E. \Vilson (Fig. 2). This lit-ic joitms the anterosuperior with the losterosuperior aimgle of time calcaimeus. Lateral roentgeimographic i mmterpretation, as was pointed out by C. E. Wilson in 1950, is also dependent on the positiotm of tiw foot at ti-ic time that ti-ic roentgenogram is made; that is, vhetimer the foot
is inverted or eveited.

An
fractured

axial

(plaimtar)

projection

shows

the

medial

malleolus,

the
convex

lateral

mallcolus,
surfaces,

time base the

of the

fifth

sustentaculum

metatarsal, tali

medial (Fig. 6-B),

concave and at-id fracture

lateral of the

articular surface (Fig. 7). additional projections used by us show involvement of the articular suiface of time calcaneus at the calcaneocuboid joint, which is not evideimt in the convetmtiotmal lateral projection. The lateral-oblique projection visualizes fractures itivolving this articular surface (Figs. 6-C at-id 6-D), as well as fractures involving the anterior process, whereas ti-ic anteroposterior projection of the mid-tarsal
Time two joints shows fractures involving the articular surface of the calcaneus at the

l)osterior

calcaimeocuboid joint, which frequently are associated with a lateral spreading displaceim-ient of the lateral cortex at the joint (Fig. 8-B). As has been pointed out by Conn, depression of the articular surface and joint incongruity are also present. In the more severe fractures, medial subluxation of the talus at the talonavicular joint takes place (Fig. 9). There has beet-i lack of emphasis on the importance of these two projections which portray fractures involving the anterior articular
surface as well as any abnormality
il-i

the

talonavicularjoint.

We

believe

that

sot-i-ic

of the unsatisfactory results encountered in the past with treatment other than triple arthrodesis are because of the lack of recognition of the associated injuries involving the two peritalar joints. Proper evaluation of the extent of time comminuted displaced fractures is only possible on the basis of these five roentgenographic projections.
VOL. 41-A, NO. 8, DECEMBER
1959

1426

K.

R.

THOMPSON

AND

C.

M.

FRIESEN

CLASSIFICATION

In

1952 Group

Essex-Lopresti presented a classification 1 : Not involving subtalar (subtaloid) A. Tuberosity fractures 1. Beak type (Boyer) 2. Avulsion of medial border 3. Vertical
4.

of caicaneal joint

fractures:

Horizontal
.

Group

Involving calcaneocuboid joint 1 Parrot-nose type 2. Various 2: Involving subtalar (subtaloid) joint A. Without displacement B. Tongue type, with displacement C. Centrolateral depression of joint D. Sustentaculum tali fracture alone E. With gross comminution 1 From below (including severe tongue
.

B.

and

joint-depression subtalar (sub-

types)
2. From behind forward, with dislocation,

taloid) joint
This paper considers only those fractures of the second group, with displacement and involvement of the subtalar joint. In B (tongue type with displacement), C (centrolateral depression of the joint), as well as E (with gross cornminution), decreased tuber-joint angle, cornminution, and deformity are exhibited. We found that these fractures exhibit, in addition, extension forward of the fracture into the cuboid articular surface, with lateral spreading. Also common, and evident in the more severely comminuted fractures, is subluxation of the talar head at the talonavicular joint. Fracture of the cuboid articular surface of the calcaneus should always be considered as an aspect of comminuted fractures of this bone because of its usual occurrence and the disability it produces. We believe that the fracturing force bows the lateral cortex of the calcaneus like a barrel stave, producing the lateral spread of the bone and the extension of the fracture into the articular surface at the calcaneocuboid joint (Fig. 10).
REVIEW OF TREATMENT

In 1938 Goff presented a comprehensive review of the literature which ineluded 151 references. The disability produced by comminuted fracture of the caicaneus was recognized early, and in 1912 van Stockurn reported open reduction with subtalar arthrodesis. Magnuson drew attention to the upward displacement of the posterior fragment and, in 1917, recommended subcutaneous tenotomy of the Achilles tendon to eliminate this upward pull, combined with manipulation to break up the impaction and force the heel downward. He immobilized the foot in a plaster cast in a position of strong inversion and equinus. In 1923 he was the first to recognize the lateral piling up of bone beneath the external malleolus and recommended removing this mass and creating a trough for the peroneal tendons. This was followed by manipulation of the calcaneus, shifting it medially with the use of a wrench if the subtalar joint was not ankylosed and if manipulation was possible. Cotton also called attention to the disabling aspects of the piling up laterally, as did Cabot and Binney. With continued dissatisfaction with results obtained from closed manipulative procedures, attention was focused on surgical management. In 1927 P. D. Wilson pointed to the contributions of Conn, Allison, and Reich, who, in 1926, recommended arthrodesis of the subtalar joint. He reported twenty-six patients on whom he did twenty-eight subtalar arthrodeses. In his experience, early operation-that is, on patients with recent fractures-gave the best results, with an
THE JOURNAL OF BONE AND JOINT SURGERY

COMMINUTED

FRACTURES

OF

THE

CALCANEUS

1427

..

,fr

Ftc.

6-A

Fin. 6-13 Lateral

roentgetmogram of of calcaneus,

Fig. 6-A: Case fracture. Fig. 6-13: Axial luin tali.

I (Table
(plant
ii)

II).
meat

the

calcaneus,

showing tire of

a toimgue-tvpe

gcnograimm

time

showiimg

a fract

t lie sustentaru-

Fic. 6-C
Fig. 6-C:
involveimment

Fia. &-D
time positioniimg joint. of for time lateral-oblique view, to

Photograpim showing of the calcancocuhoid

show extending

fracture

Fig. 6-1): Lateral-oblique roermtgermogranm time cuhojd articular surface. avetage

the calcaneus,

showumg

the fracture

into

tmmethcul also
h)llti(l

(listti)ility (lid less

period of live and one-half timonths. Old W(ll, with an average (lisal)ility period

fractures of eight
ill
5011W

l)(tfoltmled

that
to gone

results

aim tLIthro(lesis seetne(1 to

that occasionally that by

of the talonavicular l)e ituproved by this

time calcatmeOCul)Oid

joint addition.

lie

fit.st has

mnetitioti

articulation

time fracture.

It is belieVc(l
unrecognized

his (letectiOti
subsequent

is of key

itnportance,
of

treated by this mmotmths. Wilsotm itmstances, and was atnotmg time is involved by and otie which
time counminuted

niatmy

itmvestigators

fracture. To further cite Wilson, he believed that a foot is better, solidly fused in a Iosition of optimum function, than with limited tnotion, unfused and paitiful. lie believed that there is tmo great amouimt of remaining motion, regardless of treat meimt. It-i the following decade ti-ic pendulum swung back, at-id closed treatment tame into vogue agaitm. In 1931 B#{246}iuler escribed d his InetilOd, in which he utilized skeletal fixation with Steintnatmti pitis it the tuberosity of the calcaneus at-id in the lower tibia. The significant feature of this method was the attempt to achieve at-i accurate reduction usitmg time tuber-joint angle as a guide. This angle, which he
VOL. 41-A. NO. 8. DECEMBER 1959

1428
I
=

K.

R.

THOMPSON

AND

C.

M.

FRIESEN

described,

is formed

by

the

intersection

of

-----------. FIG. Axial (al(aneus, l)osterior (iilantar) showing articular

7
of of

.
the time

a line drawn along the upper contour of the tuberosity and a lit-ic uniting the highest point of the anterior process with the highest point of the posterior articular surface. This angle is usually 30 to 35 degrees. B#{246}hleremphasized the significance of this atmgle in the diagtosis at-id reduction of fractures of the calcatmeus, but whet he used it as a guide to reduction he did tmot take itito consideration the fact that even though the atmgle is restored, the joitmt surfaces may miot i)e returtmed to nortmmal nor tnay comnmnitmuted fragmeimts be realigtmed. B#{246}hlerreported the use of this method of treatim-ient
in 100 cases

roentgeimogranm time fracture surface.

but he did not give etid-tesult statistics. This method was somewhat uniformnly adopted, with efforts directed to techmuiques to restore the contour of the calcaneus.

Corm, il-i 1935, was among the first to appreciate the extent of these fractures as well as to anticipate disability. He found 85 per cent of fractures of the calcaneus to be of the smashed type. He pointed out, in his anatomical description, that frequently the sustentaculum tali is depressed and the subtalaf joint disrupted. He also noted that the talonavicular joint is often subluxated and that the fracture involves the calcaneocuboid joint. He emphasized that, with these alterations in joint alignment and the resultant disturbance of the normal weightbearing thrusts, the reason for both the pain and the failure of simple subtalar fusion is quite evident. He proposed a two-stage method of treatment. First, the impaction was broken up by using a heavy wooden clevis, and the fracture was immobilized by a modification of the B#{246}hlertechnique. In the second stage, five weeks later, a triple arthrodesis was performed. He reported on nineteen fresh fractures treated by this method, with excellent results in all but two. Triple arthrodesis on six old fractures gave five good results. Other modifications of the original Cotton procedure were described by Hermann it 1937 and by Goff in 1938. In 1943 Gallie reported his operative procedure of subtalar-joint fusion for which he used a posterior approach. He

/
I

FIG. Fig.

8-A

F1(.

8-B

8-A: Photograph showing positioning for the a1mteropost4rior view visualization of the talonavicular and calcaneocuboid joints. Fig. 8-B: Aimteroposterior roentgenogram of the mid-tarsal joitmt, showing
into the

of time nmid-tarsals the fracture

AND JOINT

for

extending
SURGERY

calcaneocuboid

joizmt,

with

lateral

spread.
THE JOURNAL OF BONE

COMMINUTED

FRACTURES

OF

TilE

CALCANEUS

1429

t
1 CAL CAMEl

1t(;.U
lig. U : 1It(io!asteiior
iO(iltgeiiOgialfl of

Ftc.
joint and t ime niid-tarsal joint sui)luxation of t lme imead
of
,

10

shmoving
of t

I he

cxten(lnmg with Fig.

Fig.
of t in

iimto the (alcaneocul)oid 8.13).

!)raving
)Oi

he talus

fract ore (compare

10:
(Ui

of

the

authors

coimception

the

mecharmisnm

of fracture

involveument

I art icular

surface.

Case
esis, six traiisfixing

5 (Table

I).

Lateral

roentgeimogram
after operation, joint.

of a triple
showing

arthro(ltime staple

arm(l one-half years time caicarmeocui)oi(l

listed
1946, traction,

varus

of

the

heel

or

other

deformities

as

contra-indications.

Harris,

in

recommnen(led

he

did

plaster
utilization

a t1mree-pintype of traction, which he labeled tn-radiate in which he used a ring with screw adjustmetmts. Ten days after reduction a 1)ostenior subtalar fusion of the (Jallie type through a window in the at-id removed plaster at-id pit-is eight weeks later. lie also recommended
of a Steinmnammn

pim

driven

it-ito

the

heel

to

pry

up

the

depressed

frac-

was also necommnended later by Gissatme. Geckeler and Dick each reported his results of treatment by subtalar arthrodesis; Dick used grafts of canceilous botme, either homogenous from the bone bank or autogenous from the iliac crest. Of ti-ic nine patients he reported, all showed sound fusions and returned to work within an average period of six au-id one-half months. In 1946 Pridie described excision of the calcaneus in the treatment of these severe fractures. He believed that this was indicated because of the disruption of the subtalar joint with the resultant stiffness, pain, and disability which usually follow this type of fracture.
tures; this
VOL.

41-A.

NO.

8. DECEMBER

1959

1430

K.

R.

THOMPSON

AND

C.

M.

FRIESEN

TABLE
COMMINUTED FRACTURES
IN

I
TREATED
ASSOCIATED

OF

THE

CALCANEUS
WITHOUT

BY

PRIMARY
INJURY

TRIPLE

ARTHRODESIS

PATIENTS

Roentgenographic Age Patient Healing

Back

to Work

Results

Length
Follow-up

of

(Years)

Sex

Side
It
L I L R L R

Occupation
Farmer Teacher
Tobacco laborer Construction

(Months)
5 3 .3
:3 3 .5

after Surgery (Months) 6

4 6
6

(Years) E
E 1 U

1 2
:3 I 5 6 7

58*
36 4:3* 49*

M
M M M

2
7.7 7 I

worker
55t 37*

ri
M

Roofer Mover
Truck driver

3
3 4

7
7 7

E
E E

6.5 6.5
1

49

3
3

6
6

E
E

3.3
5

8
9 10 11 12 13 14 15

45*t
30
35*t 35* 47* 30* 6O 39*

M
M
M M M M M M

R
L
R R L R It R

Exercise
Farmer Farmer
Tobacco

boy

3 3
worker

7 4.5
5 4 5 5

E E
G E E E

1 4.5
.5 1.5 1.3 .7

Lumberworker
Laborer

3
3 3

Mason Farmer
Tobacco laborer

4
3 4

5
4 11

E
E F

1.5
2.3 2.5

16
17

28*
49

M
M

R
R

Contractor

18 19

49 56

M M Averages:

L L

Carpenter Electrician

2.5 3 3.3

11 5
6 .0

G E

1.8 8.5
3 .1

*Compnsab1e
tBilat.eral fracture.

cases.

excellent;

good;

fair.

The results in two of the fifteen cases he reported were not satisfactory, and amputation was necessary in one. In 1948 Palmer described open reduction and elevation of the depressed fragment of the posterior articular surface after a transfixion wire was placed in the tuber calcanei in order to apply downward and backward traction. The cavity left by elevating the fragment was filled with a graft of cancellous bone from the ilium. Essex-Lopresti, in 1952, described open reduction, pointing out that in 1902 Morestin first advocated open reduction. Open reduction was also described later by Leriche in 1913, by Lenormant, Wilmoth, and Lecoeur in 1928, and by B#{233}rardand Mallet-Guy in 1929, as well as by Simon and Stultz in 193 1 In the procedure described by Essex-Lopresti a graft was not used in the early cases since it was found that the cavity filled with cancellous bone and was not visible roentgenographically after eight weeks. However, if the operation was not performed within two weeks of injury, there was the likelihood that the cavity would not fill with new bone. In 1955 Allan and Maxfield and McDermott reported their experiences with open reduction and bone-grafting, using the technique described by Palmer. Whittaker, in 1947, described open reduction through a medial approach done on three patients ; his eight-year follow-up was reported in 1954. In 1957, Thompson and Hughes and Leonard recorded their results after open reduction and grafting. Leonard used hornogenous bone in order to avoid disability at the donor site.
.

RATiONALE

AND

INDICATIONS

FOR

TRIPLE

ARTHRODESIS

From the literature it would appear that comminuted, displaced, calcaneal fractures cannot be successfully treated by closed manipulative procedures. Essex-Lopresti defined the comminuted fracture as one which has a primary fracture line which involves the body anterior to the posterior articular surface and a
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1431

TABLE
CuI-iiIx
UlEl)

II
TREATED BY PRIMARY fRI liE ARTIIRO1)ESN

FRM

It

lIES

OF

THE

CALCANEUS

IN

1ATIENTS

WITH

ASSOCIATED

INJURY

Age

Roentgenographic Healing

Back to Work
after Surgery

Length
Follow-ui)

of

Patient

(Years)

Sex M
M #{149};t F #{149} M

Side R
it it It L

Occupation Student

(.ifonths)

(Mont/is)

Resultt

(Years)

1
2 3 4

20
:32* 44*
21

:3
:t . 5 3 2.5
3 .5

Riveter
Carpenter housewife

I 7
8 9

1 E
E li

5.5
U 6.7
4.5

5 6

3O 59*
*Compensai)le

Druggist
Carpenter
tE
=

M Averages:
cases.

:3 3. 1 excellent; U
=

I1 10 8.2
good; F
=

E E
fair.

4.7 6.3

6 1
.

secondary fracture lit-ic which traverses the body just behind the joimt. The fnagment outlined by these fracture lines includes the lateral half or lateral two-thirds of the posterior articular surface. When displacement occurs this fragment is driven downward while the tuberosity is driven upward. The primary fracture
line opemms infeniorly, and there is associated widenimmg of the body of the calcaneus

due to lateral displacement of the fragments. In addition, cases, another fracture lit-ic extemds forward ot the lateral surface at the calcaneocuboid joint. In the past, arthrodesis of the im-ivolved joitmts has various investigators on the assumption that irreparable
surfaces
arthritic

as demonstrated side into the beenrecomrnended damage to the

of the fragments

in our articular by articular

amid

has
changes

occurred

ani

that

aseptic

necrosis

of

some

vill supervene. A one-joint or subtalar fusion was recommended at first. Them-i a two-joitmt arthrodesis including the subtalar and talonavicular joints was recommended by Wilson in 1927. Finally, a three-joint or triple arthrodesis was advocated in 1935 by Conn and subsequently by Geckeler who emphasized the importance of doing a triple arthrodesis when the calcaneocuboid joint was involved. With the realization that the calcaneocuboid joint is frequemitly involved it is our feeling that more surgeons will want to recommend triple
arthrodesis.

By appropriate roentgenographic technique we have beet-i able to identify the comminuted displaced fractures which disrupt the subtaiar joint and involve the cuboid articular surface of the calcaneus at the calcaneocuboid joint as well as cause alteration of the tuber-joint angle and lateral spreading. Patients with these fractures have been selected, irrespective of their age, for primary triple arthrodesis. Twenty-five patients with twenty-six fractures treated by this technique are reported in this study.
PREOPERATIVE CARE

Care before surgery varied, depending primarily on the general condition of the patient and on the interval betweemi injury al-id examination. Surgery was undertaken promptly before there was marked swelling if the patient was seen early. When the patient was not seen early, and when swelling was significant, general supportive measures were used until the local skin condition was believed to be satisfactory for operation. In some instances it was necessary to wait for edema blisters to heal, particularly when the fracture was severe ar-id the patient had not been referred for treatment until several days after injury. In six instances, operation was delayed because associated injuries did not permit early surgery.
SURGERY

Surgery, talonavicular,
VOL. 41-A, NO.

in all cases, consisted and calcaneocuboid).

8, DECEMBER 1959

in primary In no instance

triple was

arthrodesis (talocalcaneal, there an attempt to reduce

1432
or

K.

R.

THOMPSON

AND

C.

M.

FRIESEN

itnprove fracture alignment by closed procedures. The operation is perfortmcd, usitmg tourniquet control, with the patient inclined to the opposite side. The hip and knee are flexed approximately 30 to 40 (leglees; the leg, ankle, at-id inner foot are placed on a sandbag so that the heel extends over the edge into yams position. The skin incision is of at-i Oilier type, which extetmds from the region of the lateral border of the extensor tendoum mmear the talonavicular joint, transectitig the sinus tarsi and continuing posterior to an area an inch inferior to the external malleolus. The skin is reflected with the underlying soft tissue and should not be undermined. The origin of the short extensor muscle is then reflected distally, and the sinus tarsi is entered. The dissection is extended to expose the calcaneocuboid joint, the talonavicular joint, and the talocalcaneal joitt. The extent of the fracture of the calcaneus is then observed. Itm each instance an attempt was made to accurately tabulate the findings at surgery, with particular reference to the fracture of the cuboidarticular surface arid of the subtalar joint. In some instances the peroneal tendon sheath was opened and the tendon reflected, in order to better expose and visualize the cxtent of the fracture. Frequently, the anterior process of the calcaneus was fractured and displaced. Whether fractured or not, it is removed, and the calcaneocuboid joint is resected. The capsule of the talonavicular joint is opened, and exposure is facilitated by stripping the capsule on its medial aspect with a Hatt spoon. This joint is then removed, and the subtalar joint is excised. This can be facilitated by removing the anterior margin of the posterior calcaneal articular surface of the talus which projects downward and anteriorly and somewhat obscures the joint. The cartilaginous surface of the talus is first removed, affording better visualization of the articular surface of the calcaneus and its comminuted pieces. Small, loose fragments are removed, and their articular surfaces are denuded before they are replaced. The depressed articular surfaces are elevated by means of an osteotome, which is placed between or beneath them. Manual latera! and medial compression helps to stabilize their position. Control of the fragments temporarily can be secured by means of a Kirschner or threaded wire introduced through the lateral cortex to facilitate denuding of the articular area. Removal of the cartilage from the middle articular surface is facilitated by means of stabilization with a pin inserted from the medial aspect of the foot. General reduction and apposition of the denuded surfaces are accomplished under direct vision. In most instances a staple is used to secure the calcaneocuboid joint (Fig. 1 1). The lateral fragment is manually compressed to eliminate any lateral piling up. A Kirschner wire is then inserted through the heel pad into the lateral fragment or cortex to prevent recurrence of lateral spread and to secure it soundly to the talus. In some instances a second staple has been placed from the lateral border of the calcaneus into the talus to prevent recurrence of lateral displacement (Fig. 5-B). Pin fixation has been utilized, as deemed necessary, to properly secure apposition of the denuded surfaces, as Caldwell recommends for triple arthrodesis. Occasionally, a second wire has been placed through the heel pad into the medial fragment of the calcaneus to secure it when there has persisted a tendency for it to be displaced. It has been found that contact, alignment, and stability are accomplished by the use of staples and Kirschner wires

or pins. The
mated. A leg

extensor-muscle
plaster cast

origins are replaced, and soft tissue is reapproxiincorporating the plantar wires or pins, and

is applied,

the tourniquet

is then released.
POSTOPERATIVE MANAGEMENT

arthrodesis, including proper elevation of the leg. The degree of comfort encountered, after the first twentyfour to forty-eight hours, in patients who undergo triple arthrodesis early is surprising when compared with that in patients whose associated injury necessitates delay. The patient is usually allowed up in a wheel chair on the third or fourth postoperative day, and walks with crutches on the seventh to tenth postoperative
THE JOURNAL OF BONE AND JOINT
SURGERY

The

care after surgery is as usual for a triple

COMMINUTED

FRACTURES

OF

THE

CALCANEUS

1433
the fourth or fifth weeks, and, three to therapy to the ankle or high-top shoe, and

day. week.

eight four weeks later, the plaster cast is removed and physical is instituted. The patiet-it is either fitted with a leg brace weight-bearimmg with crutches is started.
OPERATIVE FINDINGS

The plaster Weight-bearing

cast

is changed, in a plaster

with cast

wire removal, is started at

during

The
consistent

extent
with

of the
the

fracture,
roentgenographic

as noted of the fracture

when

surgically
of

exposed,
the injury;

was

somewhat
almost uni-

immterpretation

to be greater than susin all roemmtgenograms prior to surgery, arid at-i attempt was made to determine whether the fracture itmvolved the cuboid articular surface. This itivolvement was showim l)y roentget-iogram in twetity-five fractures and was verified in all of them at the tin-ic of operation. The involvement of the subtalar joitt by the fracture was always found to be immre extensive that was anticipated from the roentgemographic evaluatiom-i. Frequettly, small, comrninuted, detached, articular fragments were foutmd which, im son-ic instances, had beet-i driven deep into the cancellous area. With fracture of the
sustentaculum

formly, pected.

however, the The appearance

severity of the

fracture was was scrutinized

found

tali

and

associated

longitudinal

split

it-i the

posterior

articular

surface, driven of the

the down smaller

two articular surfaces formed a V, with fragments which had below the articular level. It was impossible to properly replace comminuted fragments, and it seems impossible to accomplish
of such a joint by closed or open procedure. The subluxation

beeti son-ic anaof

tomical reduction the talus at the

but not surface.

with

talonavicular the frequency

joint was with which

noted in some of the the fracture involved

more severe the cuhoid

injuries, articular

ANALYSIS

OF

CASES

The data for the patients under study are presented in Table I and Table II. In order to reflect more precisely the result of primary triple arthrodesis, these patients have been divided into two groups : those without associated inj ury (Table I) and those with associated injury (Table II). The ages of the twentyfive patients treated ranged from twenty to sixty years, with an average of 41.4 years. Twenty-four patients were male; one was female. In Table I are included patients 5, 8, and 10 who had bilateral fracture of the calcaneus; Patient 5 had bilateral comminuted fractures; Patient 8 and Patient 10 had undisplaced fractures of the left calcaneus, which did not involve either the subtalar or calcaneocuboid joint and did not require operative treatment. Of the twenty-six primary triple arthrodeses which were done, sixteen were on the right and ten were on the left. Twenty-one of these patients were laborers;
fifteen of them had competsable injuries. Three other patients had injuries which

involved liability claims. The associated injuries, as listed im Table II, were those of: Patient I who had fracture of the second lumbar vertebra; Patietmt 2, who had commitmuted fracture of the mid-shaft of the right humerus; Patient 3, who had fracture-dislocatiomm of the left humeral head; Patient 4, who had multiple fractures involvimmg the pelvis with acetabular displacement and a compound, comminuted fracture of the midshaft of the right femur; Patient 5, who had supracondylar fracture of the right femur and bimalleolar fracture of the right ankle; and Patient 6, who had an extensive comminuted fracture of the right tibia, involving the ankle joint, with displacememmt, necessitating ankle fusion.
,

RESULTS
r

he patients

reviewed

iimclude

all those

on whom The duration an average as judged

a primnary

triple

arthrodesis from by

was performed from 1948 through 1956. six months to more than nine years, with Healing time of the triple arthrodesis,
VOL. 41-A, NO. 8, DECEMBER 1959

of follow-up ranged follow-up of 3.8 years. roentgenographica!ly

1434

K.

R.

THOMPSON

AND

C.

M.

FRIESEN

restoration of trabeculae across the arthrodesed joints, averaged 3.2 months. Those patients without major associated injury returned to work on an average of six months after surgery, whereas those with associated injury required an average of eight months before returning to work. All patients returned to their former employment. The average time after surgery at which the twenty-five patients went back to work was 6. 5 months. The average time at which the twelve patietits with compensable injuries without associated injury returned to work was 5.3 months, whereas those of this group who did not sustain industrial injury returned to work in 7.3 months. There was one complication, consisting of drainage, which began approximately six weeks after operation ; culture and smear were negative. A staple at the calcaneocuboid joint was removed approximately four months after surgery, but minimum drainage persisted. Sequestrectorny of a bone fragment at the calcaneocuboid joint was performed approximately eighteen months after triple arthrodesis. This patient died two and one-half years after his injury from a rupture of am-i aneurysm in the circle of Willis; prior to his death, healing had occurred. Roentgenographically, this patient had a pseudarthrosis of the calcaneocuboid joint, resulting from sequestration of a fragment of bone at this joint. A pseudarthrosis at the talonavicular joint developed in another patient, but neither of these patients had symptoms referable to their pseudarthroses. Twenty-one patients (84 per cent) were rated as having obtained excellent results. These were those who returned to their former occupations with no pain arid no restriction of their activities. The loss of inversion and eversion which resulted from the primary triple arthrodesis was not considered by the patients to restrict ammy activity which they wished to perform. There was no detectable alteration in gait. Three patients (12 per cent) were rated as having obtained good results; they returned to their former occupations and had no serious interference with their activities although they all had a mild limp, mild discomfort, or some minor complaint. One patient was rated as having a fair result because of postoperative drainage; he, however, experienced no pain or restriction of physical activity and he walked with a normal gait. In some feet there was residual broadening of the heel, which has not, however, produced any functional impairment or symptoms. In two patients with long-term follow-up, an exostosis developed on the dorsal aspect of the neck of the talus. This occurred in one of the feet of the patient who had had bilateral primary triple arthrodesis. Whether this condition results from the injury or from some other cause is not known. There was no significant impairment of ankle motion except in the one instance of an exostosis, as just described, in which there was 10 degrees of restriction of dorsiflexion. An interesting observation was made in two patients who had had bilateral fractures of the calcaneus which were treated by a primary triple arthrodesis for the comminuted fracture on one side and by a short period of immobilization in a plaster cast for the undisplaced fracture on the other side. When re-evaluated, four and one-half and five years later, respectively, both patients stated that the foot treated by triple arthrodesis was more comfortable than the other foot.
CONCLUSION

From consisting

this of

study fracture

it has

been

found

that

the

severe,

comminuted,

displaced

calcaneal fracture is associated cuboid joint Wand, in some

with

involvement

of the two

peritalar joints
calcaneohead at for the calcaneus, of the two results reis irrepassociated
SURGERY

of the articular surface of the calcaneus at the instances, associated subluxation of the talar the talonavicular joint. The conventional projections are not adequate roentgenographic examination of the comminuted, displaced, fractured and two additional projections as described are necessary. Involvement peritalar joints affords an explanation for some of the unsatisfactory ported in the past. We believe that the injury to the talocalcaneal joint arable and that fusion of this weight-bearing joint is necessary. The
THE JOURNAL OF BONE AND JOINT

COMMINUTED

FRACTURES

OF

THE

CALCANEUS

1435

injuries normal primary

of the two peritalar joints similarly prevent functiomm. It has been our experience that triple treatment of timese fractures has given extremely
REFERENCES

the restoration of their arthrodesis as the initial gratifying results.

1.

ALLAN,

J.

H. :

The

Open

Reductiolm

of Fractures

of

the
in in

Os

Calcis.

Ann.

Surg.,

141 : 890-900,

1955.
2.
ALLISON, NATHANIEL:

Timirtieth Thirtietim
1926. 27 : 1 100,

Report Report

of Progress of Progress

Orthopedic Orthopedic

Surgery. Surgery

Arch.

Surg.,

13:

445-458, r 3.
p 4.
, 5.
6. ALLIsoN,

1926.
NATHANIEL:

(contd).

Arch.

Surg.,

13:

605-614, J.,

BELL, CHARlES: Edinburgh Med.

in Mr. Bells Wards: Compoutmd Fracture of Os Calcis. 1882. BRARD atl(l MALLET-GUY: A propos do traitenment sanglant des fractures r#{233}centesdu calcan#{233}um. Lyon Chir., 26: 453-456, 1929. B#{246}HLER, 14. : Diagnosis, Patimology and Treatment of Fractures of Os Calcis. J. Bone and Joint Surg., 13 : 75-88, Jan. 1931.
Statistics of Operatiotms CABOT, HITcH, and BINNEY, HORACE : Fractures of

7.

the Os Calcis
Course

and Astragalits.
Lectures, The

Ann. Surg.,
American

45:51-68,

1907.
of C. A. : Arthrodeses of the Feet. Orthopaedic Surgeons, 1949. In Vol.
Instructional

8.
9. 10. 11.
12. 13. 14.
15.

CALDWELL,

Academy

6,

pp.

17-1-177.

Ann

Ari)or,

J.

\V. E(Iwards,

1949.
CLARK, Coxs, Surgery

( )s Calcis. Latmcet, 1 : -103-404, 1855. In Irmstriictiotmal Course Lectures oti Itecormstrtictive of the Extremities, Time American Academy of Orthopaedie Surgeons, 19.14, PP 137147. Ann Arbor, J. \V. FAlwards, 1946. CONN, H. H.: Fractures of the Os Calcis: Diagnosis and Treatment. Radiology, 6: 228-235,
Calcis.

LE GRos: Fracture of the H. R. : Fractures of time Os

1926.
CONS,

H.

405, Apr.
Corrox, CorroN,

H. : Time Treattmment 19:35. F. J.: ()ld F. ,J. : Os Os

Calcis

of Fractures Fra(tures.

of the

Os

Calcis.

J. Bone

:111(1 Joint

Surg.,

17:

392-

Calcis

Fracture:

Ann. Remo(leling

Surg., 74: 294-303, 1921. with Mallet. Surg. Clitm.

North

America,

917-918, 1921. 16. 17. 18.

19. 20. 21.
Corrox, F. J., armd H:N1:Rsox, F. F. : Results of Fractures Surg., 14: 290-298, May 1916. CorroN, F. J., and \Vti.sox, L. T. : Fractures of the Os Calcis.

of the
Boston

Os Calcis.
Me(1. and

Atim. J. Orthop.
Surg. J.,

159:

559-565,
DESFOSSES: DICK, I.

1908.
of Fractures of

Cited by (ioff. L. : Prinary Fitsioti of time Posterior Sul)talar Joint iii time Treatnment the Calcaneutmi. J. Botme :111(1 Joint Surg., 35-B : 375-:380, Aug. 195:3. ESSEX-LOPRESTI, PETER: Time \Iechanistmm, He(ltlction Tecimnique, and Results the Os Calcis. British .1. Stirg., 39: 395-419, 1952. GALLIE, \V. E. : Suhastragalar Arthrodesis in Fractitres of time Os Calcis. J. Surg., 25: 731-7:36, Ot. 194:3.
GARANGEOT:

jim Fractures
Bone and Joint

of

Cited

l)y

Goff. Fractures of tIme Os

22.

GECKELER,

E.

0. : Conmnminuted
1950.

Calcis.

Cimoice Fractures
36:

of

Treatnment.

Arch.

Surg.,

61 : 469-476,

2:3.
24. 25. 26. 27.
28. 29.
:30.

GISSANE,

W. : [News

and
GOFF,

Joint
C.

Sllrg.,
W.: It.
0.

Notes. British 29: 255, Jan. 1947.

Fracture of Atmim. of time Sing., the

Orthopacdic
Os Cahis.

Society.l
Arch. Surg.,

of the Tn-Radiate
J. Botme

Os Calcis. Traction
and Joint

J. Bone

Fresh

744-765,

1938.

HARRIS,

I. :

Sttbastragalar
ITERMANN,

Fractitres Fusion.

Os Cahis.
124:

Their

Treatment

by

and
Surg.,

J.:

ConservativeTheralw

1082-1100, for Fracture

1946. of time Os Calcis.

19:

709-718,

LENORMANT, LEONARD, LERIcHE: r#{233}sultat rJAGNUSON,

can#{233}um.Iltill.

tumd LFOEUR: A 1)01)05 do traitenmetmt sanglant (1(s fractures et M#{233}nm. Soc. Nat. de Chir., 54: 1353-1355, 1928. M. H.: Treatnwtmt of Fractures of the Os Calcis. Arch. Surg., 75: 990-997, Fracture coImpli(l1ee (lit cal(:mtmeurn: rsectiotm inmImM(1iate: gintisorm avec fonctiotmtmel. Lyon Ml., 120: 1185-1 187, 1913. I. 13. : An ( )peratiotm for Relief of Disability in ( )ld Fractures of Os Calcis.
80: 1511-1513,
\lecilatmi(5

July 1937. WII.MOTIt,

do

(al-

1957.
excellent

J. Aiim. 530-532, of

Med. :31. 1917.

Assn.,

1923.
of Fractures of time

MAGNUs0N, MAXFIELD, Fractures PALMER,

1. B. :

Os (alcis.

.J. Am.

Med. Painmer
.Jan.

Assim., ()petm 1955.

68:

32.
3:3.
:34.

.1. F., and McI)r:R1oiT, F. J. : Experieimces with time of time Calcaneus. .J. Boime aimd Joint Surg., 37-A : 99-106, IVAR: Time )1ec1-iatmisimm and Treatnment of Fractures of time

Reduction

of Catmeellous (lrafts. .J. Borme and Joint Stitg., 30-A VICTOR: 1)e la fracture (1(1 talcatm#{233}unm par tcrasemetmt cutives, p. 64. Paris, Timesis, No. 249, 1880. 35. PRIDIE, K. H.: A New Method of Treatnmetmt for Severe Fractures of the Os (alcis. A Preliminary Report. Surg., Gvtmee., atmd Ohstet., 82: 671-675, 1946. 36. REICH, 13. S.: Subastragaloid Arthrodesis itm the Treatment of 01(1 Fractures of time Calcatiens. Surg., (iytmec., anti Obstet., 42: 420- 122, 1926. :37. SHEPHARD, EnMUND: Tarsal Movenments. J. Bone and Joint Surg., 33-B: 258-263, May 1951. :38. SIMON, 13., and STULTZ, EDGAR: Operative Treatnment of Conipression Fractures of the Calcaneus. Anim. Surg., 91: 731-738, 1930.
PAszKowsKl, VOL. 41-A. NO. 8. DECEMBER t959

sith

the Use

Caleaneus. Open Reduction : 2-8, Jatm. 1948. et des clfornmatioxms corms&

1436
:39. THOMPSON,

K.

R.

THOMPSON

AND

C.

M.

FRIESEN of

40.

M. S., and HUGHES, F. H., JR. : Open Treatment U. S. Army Europe, 13: 267-268, 1956. VAN STOCKUM: Operative Behandlung der Calcaneus-und

Os Calcis

Fractures.
Zentralbl.

Med. Btmll. f. Chir.,

74: 378-379,

Taiusfraktur.

39: 1438-1439, 41.

42.
WHITTAKER, WHITTAKER,

1912.
Fractures of

A. H.: A.

the Os Calcis.

Preliminary

Report.

Am. J. Surg.,

Fixation.

43.
44.

45. 46.

H. : Treatment of Fractures of the Os Calcis by Open Reduction and Internal J. Surg., 74 : 687-696, 1947. WHITTA.KER, A. H. : Open Reduction Treatment of Fractures of the Os Calcis. Indust. Med. and Surg., 23: 439-442, 1954. WILMOTH, P., and LECOEUR, P. : Le traitement op#{233}ratoire des fractures sous-thalamiques dim calcan#{233}um. Reduction sanglante et greffes osseuses. J. de Chir., 33: 781-792, 1929. WILsoN, G. E. : Fractures of the Calcaneus. J. Bone and Joint Surg., 32-A: 59-70, Jan. 1950. \VILs0N, P. D. : Treatment of Fractures of the Os Calcis by Arthrodesis of the Subastragaiar Am.

Joint.

J. Am.

Med.

Assn.,

89:

1676-1683,

1927.

DISCUSSION DR.
JOHN HAMILTON ALLAN, CHARLOrFESYILLE, VIRGINIA: Fractures of the caicaneus con-

tinue
results geon,

to remain

the most

disabling

of all industrial
various methods

injuries.
of closed

One reason
reduction,
that

for this
and the
simple

is that

poor end
sur-

have been obtained by the not caring to do arthrodesis

discouraged
immobilization

or an open reduction,
made in this paper

has concluded
which deserve

is as good

as any

form

of treatment.
observations not to neglect emphasis:

There are several 1. It is imperative prevent disability. 2. Comminuted

this

fracture,
cannot

but to treat
be treated are

it early

and

definitively
by any the

in order
of the closed

to

fractures

of

the

calcaneus

successfully to reveal

manipulative
3. Multiple of the

procedures.
roentgenograms projected is always as described essential

major

fracture

lines
extent

and

to determine
fracture

whether
damage

the calcaneocuboid
much greater

and

talonavicular
visualized fractures are with

joints
directly

are

when

involved. The than it is in the

prin-

roentgenogram. 4. The calcaneocuboid

ciple, the results with

joint

arthrodesis

is involved in so many of these are somewhat better than they

that, as a general subtalar fusion.

Finally,

in the

technique

of their

operation

the

authors

state

that

reduction

and

apposition
it is and the
and

of the fractured surfaces are accomplished under direct vision. This is of significance because an accepted orthopaedic principle that joints should be fused in their normal anatomical functional position. When applied to the comminuted displaced calcaneus, this means that tuberosity must be pulled down, the posterior articular facet elevated to its normal position, the lateral spread corrected at the time of the fusion so that a good functional position of the
is retained.

foot

In one respect our experience with these fractures does not agree completely with that of the This paper deals with comminuted fractures involving the subastragalar joint, and the classification includes those with centrolateral depression of the joint. The authors stated that these fractures all exhibit extension forward into the cuboid articular surface. It is agreed that when the
authors. fracture
fractures

line
of

disrupts
the caicaneus

the

calcaneocuboid which present

joint, primary

arthrodesis or secondary

is indicated. depression

However, of the

there posterior

are many articular

facet

and which

do not extend

forward

into

the calcaneocuboid

joint.

These

are the ones

which

respond beautifully to an open reduction, elevation of the posterior articular facet, and insertion of a bone graft into the compression cavity as described by Palmer. Some lateral motion through the foot should be preserved if possible. I must conclude, therefore, that most comminuted fractures of the calcaneus will require the treatment advocated in this paper. However, the treatment must be designed to fit the pattern of the fracture, and, in many carefully selected cases, open reduction and retention of the reduction by the Palmer technique will give an excellent result and preserve the lateral motion through the
foot.

THE

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