Revue de chirurgie orthopdique et rparatrice de lappareil moteur (2008) 94, e8e16

Disponible en ligne sur www.sciencedirect.com

ORIGINAL ARTICLE

Results of open reduction and cortico-cancellous

autograft of intra-articular calcaneal fractures
according to Palmer
Rsultats du traitement des fractures articulaires du
calcanus par relvement foyer ouvert et greffe
systmatique selon la mthode de Palmer :
propos de 18 cas
M. Di Schino, M. Bensada, E. Vandenbussche, B. Augereau, C. Nich
Service de chirurgie orthopdique et traumatologique, hpital europen Georges-Pompidou, 2040, rue Leblanc,
75908 Paris cedex 15, France
Accepted 25 April 2007

KEYWORDS
Intra-articular
fracture;
Calcaneus;
Surgery;
Bone autograft

Summary
Objective. To assess the mid term patient outcome after operative treatment of a displaced
intra-articular calcaneal fracture using the modied Palmer technique.
Materials and methods. Eighteen operatively treated intra-articular fractures of the calcaneus in 16 patients (nine males, seven females) were retrospectively reviewed. The mean age
at surgery was 35 years (range, 1761 years). Two patients had a bilateral fracture. Following
Utheza, ve fractures (28%) were classied as vertical, three as horizontal (17%) and 10 (55%)
as combined. Mean preoperative Bhler angle was 4 (range, 42 to 26 ). An extended
lateral approach to the calcaneus was used in each case. A cortical bone autograft was rmly
impacted in the subthalamic void after reduction. Stabilization was achieved by two or three
axial Kirschner wires and one or two screws inserted in a transverse position. Patients were
evaluated at the last follow-up by physical examination and by the functional score described
by Kitaoka. Bhlers angle was measured on the immediate postoperative radiographs and at
the last follow-up, and compared when possible with the noninjured side.

DOI of original article:10.1016/j.rco.2007.04.002.

Corresponding author.
E-mail address: chrnich@gmail.com (C. Nich).

0035-1040/$ see front matter 2008 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.rco.2007.04.007

Treatment of intra-articular calcaneal fractures according to Palmer

e9

Results. Follow-up ranged from 12 to 38 months (mean, 23 months). One patient required a
subtalar arthrodesis for advanced osteoarthritis. One patient experienced reex sympathetic
dystrophy. No skin complication was noted. At the last follow-up evaluation, the mean Kitaoka
score was 74 (range, 3498). The functional score was considered good or excellent in 11
cases (64.7%), fair in three (17.6%), and poor in three (17.6%). The mean Bhler angle was
23.4 (range, 540 ) postoperatively and 22.7 (range, 038 ) at the last follow-up. A modest
loss of correction was observed in four cases. The nal Bhler angle was at least 85% compared
to the healthy side in 10 cases out of 14 unilateral fractures. The functional score correlated
well with restoration of Bhlers angle.
Discussion and conclusion. Operative treatment of intra-articular calcaneal fractures following a modied Palmer technique provided encouraging results, since restoration of Bhlers
angle was obtained. The main advantages include an absence of hardware prominence, resulting
in an absence of skin complications, and a stable xation.
2008 Elsevier Masson SAS. All rights reserved.

MOTS CLS
Fracture articulaire ;
Calcanus ;
Chirurgie ;
Autogreffe osseuse

Rsum Lutilisation dune greffe osseuse systmatique dans le traitement des fractures
articulaires dplaces du calcanus est discute. Les auteurs ont valu rtrospectivement les
rsultats des relvements associs une greffe daprs Palmer. La technique a t employe
dans 18 fractures articulaires du calcanus, chez 16 patients (neuf hommes, sept femmes), gs
en moyenne de 35 ans (1761 ans). La fracture tait bilatrale chez deux patients. La fracture
tait classe verticale dans cinq cas (28 %), horizontale dans trois cas (17 %) et mixte dans dix
cas (55 %). Langle de Bhler initial moyen tait de 4 (42 26 ). La surface thalamique tait
aborde par une voie latrale largie. La rduction du foyer tait maintenue par deux ou trois
broches axiales et une autogreffe tricorticale iliaque encastre dans le vide sous-thalamique. Le
recul moyen tait de 23 mois (1238 mois). Une algoneurodystrophie a rgress sous traitement
mdical. Une arthrodse talocalcanenne a t ralise dans un cas darthrose volue. Aucune
complication cutane ou sur le site de prlvement du greffon na t releve. Au dernier recul,
le score fonctionnel moyen de Kitaoka tait de 74 (3498), avec 11 cas (64,7 %) jugs bons ou
excellents, trois moyens (17,6 %) et trois mauvais (17,6 %). Au plan radiographique, langle de
Bhler postopratoire moyen tait de 23,4 (540 ) et de 22,7 (038 ) au dernier recul. La
perte de correction moyenne globale tait de 0,67 (25 ). Dans dix cas sur 14 unilatraux,
la restitution de langle nal tait au moins gale 85 % comparativement au ct sain. Il
existait une corrlation entre la restauration de langle de Bhler et le score fonctionnel. Le
traitement des fractures articulaires du calcanus, selon une technique drive de Palmer, a
donn des rsultats fonctionnels encourageants, conditionns par le rtablissement de langle
de Bhler. Les complications spciques taient limites dans cette srie prliminaire.
2008 Elsevier Masson SAS. All rights reserved.

Introduction
Surgical treatment of displaced intra-articular fractures of
the calcaneus is recommended by most of todays authors
[1,2]. Recent publications have shown an improvement in
functional and radiological results after surgical reduction
and osteosynthesis compared with conservative treatment
[35], although the signication threshold is not always
attained in meta-analysis [6]. The patients return to work
seems more consistent and earlier after surgical treatment [7]. However, the surgical modalities (time to surgery,
approach, bone graft, internal or external osteosynthesis)
have not met with consensus. The principles respond to
the objectives of intra-articular fracture treatment applied
to the anatomical features of the calcaneus bone. The
anatomy and the thalamic intra-articular surface must be
reestablished [810], a stable montage obtained, and complications, notably cutaneous, limited [11].
In 1948, the Swedish physician Palmer [12] reported on
the mechanism of intra-articular fractures of the calcaneus and popularized open treatment of these injuries. This
Palmer method associated lifting the thalamic surface via

a lateral approach and systematic lling of the subthalamic

void with a bone autograft, without osteosynthesis. Since
Palmer, the systematic use of a bone autograft to ll the
void related to lifting the thalamus has been rarely reported
in the literature and has shown disappointing results [5].
The objective of this retrospective study was to present
the principles and evaluate the results of intra-articular
fractures of the calcaneus using a method derived from the
Palmer method.

Material and methods

Patients
Between January 2003 and June 2005, 18 intra-articular
fractures of the calcaneus in 16 patients were treated using
a method derived from the Palmer method: nine men and
seven women, mean age, 35 17 years (range, 1761 years;
median, 31 years). The right side was involved in eight cases,
the left side in six cases. The fracture was bilateral in two
patients. Supercial skin lesions (phlyctenae) were initially

e10
present in ve cases. One case was a stage II Cauchoix and
Duparc medial open fracture.
A high-energy fracture was identied for eight fractures,
corresponding to falls in ve patients (seven fractures), from
a mid-range height of 4.9 1.5 m (range, 36 m; median,
6 m) and a trafc accident (one fracture). Voluntary defenestration in a psychiatric context was the cause of fracture
for three patients (four fractures). Two patients (three fractures) had an accident at work. For the remainder, 10
fractures occurred at home, resulting from a fall from variable heights, in all cases greater than 50 cm (a fall from
a step-ladder or a ladder or a fall down stairs). Associated lesions of the locomotor system were observed in six
patients (one open fracture of the leg on the same side as
the lesion, one contralateral femoral diaphyseal fracture,
one contralateral fracture of the distal end of the tibia, one
fracture of the ipsilateral talus, three lumbar fractures, one
of which was complicated by post-traumatic paraplegia, one
fracture of the sacrum, and two wrist fractures).
Seven patients were employed at the time of injury, three
of whom were laborers. Four patients engaged regularly in
sports. Chronic tobacco smoking was noted in six patients.
The mean weight was 65.6 11.4 kg (range, 4590 kg;
median, 66 kg) for a mean height of 1.70 0.05 m (range,
1.571.80 m; median 1.70 m), for a median body mass index
(BMI) of 22.4 3.1 (range, 18.227.8, median, 21.8). Lifting plus autograft was retained in cases of intra-articular
fracture of the calcaneus with signicant depression in
the thalamus surface. Nondisplaced intra-articular, extraarticular, and/or comminuted lesions were excluded from
this series. In particular, complex involvement of the plantar
calcaneal cortex, which made support of the graft uncertain, were excluded.
The fracture was analyzed preoperatively on plain X-rays
with a frontal and lateral image of the ankle and a retrotibial
view. A CT scan of the hindfoot was taken in all cases. The
thalamus fractures were classed according to the description by Utheza et al. [13], based on the location of the
fundamental line and the displacement of the corticothalamic fragment and according to Duparc and De la Cafniere
[14] and Sanders et al. [15]. The fracture was vertical in ve
cases (28%), horizontal in three cases (17%), and combined
in 10 cases (55%). Nine fractures were classied as Duparc
type III and nine fractures as type IV.
The mean preoperative Bhler [16] angle was 4 22
(range, 42 to 26 ; median, 2 ). Involvement of the calcaneocuboid joint was observed in three cases.

Surgical technique
The mean time between injury and intervention was 6 9.1
days (range, 023 days; median one day). Surgery was performed immediately except in three patients in whom the
skin condition made the approach impractical or when the
patient consulted with a delay (a bilateral fracture in one
patient), operated on the 22nd day.
The intervention was conducted in lateral decubitus on
an ordinary table, guided by the image intensier. The
lower limb to be operated was entirely draped, including
the ipsilateral anterior iliac crest in the eld. A pneumatic tourniquet was used systematically, except for the

M. Di Schino et al.
iliac autograft harvest, lasting a mean 58 28.6 min (range,
30140 min; median, 45 min). The mean total duration
of the intervention was 68 30.5 min (range, 45152 min;
median, 62 min). The approach was lateral retro- and submalleolar, curved and located relatively low, at the junction
of the dorsal and plantar skins in the submalleolar portion,
so as to avoid the branches of the sural nerve. The incision
extended forward to the calcaneocuboid joint. The opening was then lengthened to the periosteum, taking care not
to create subcutaneous detachment or excessive traction
on the edges. After elevating the bular tendons en bloc
in their sheath with the anterior cutaneous band using a
double-bent retractor against the greater tuberosity, the
lateral cortex, most often damaged by the fracture, was
approached. The lateral wall was elevated while preserving
a posterior hinge. The thalamus depression was then visualized after cleaning the subtalar joint. Reduction combined
lowering the great tuberosity and correction of calcaneal
varus using a Lambotte hook applied on the posterior surface
or using a transcalcaneal traction. The posterior facet was
elevated using a spatula or a transplant expelier, and temporarily held in place with a Meary forceps. If the correction
was deemed satisfactory on the lateral uoroscopic image,
the reduction was set in place using two or three 20 or 25/10
axial Kirschner wires, percutaneously at the great tuberosity, converging toward the calcaneocuboid joint without
entering it, if it was intact. The upper wire should act as
support for elevating and the lower wire(s) should reconstruct the calcaneal oor, with the entire triangular montage
supporting the depression and the axis of the hindfoot. The
pneumatic tourniquet was then released while the ipsilateral iliac tricortical graft was harvested. The central void
left by elevating the intra-articular surface was then lled by
the tricortical graft sized slightly larger than the dimensions
of the cavity and hammered in with the transplant expelier.
Spontaneous stability of the montage is required. The lateral cortex was then closed and maintained by one or two
3.5 transversal screws, transxing the graft. The operation
was terminated by closing with suction drainage, after repositioning the bular sheaths. The patient was immobilized
immediately after surgery in a posterior splint to facilitate
local postoperative care until the edema disappeared, then
in a resin boot. Second-generation cephalosporin antibiotics
(cefamandole) were given until the 24 h after surgery. An
anti-inammatory treatment (ibuprofen) was given intravenously for 48 h. Immobilization lasted a mean 81 18.6
days (range, 4590 days; median, 90 days). The wires were
removed in consultation when contention was removed.
Weight bearing was resumed progressively, with the patient
using two crutches. Preventive anticoagulant treatment
with HBPM was continued until full weight bearing was
resumed.

Revision method
Patients were evaluated by the operator preoperatively,
postoperatively, and then at regular intervals, and at the last
follow-up by an examiner not involved in the surgery (MDS).
The functional evaluation was based on a score out of
100 points described by Kitaoka et al. [17], which allowed
classifying the results as excellent when between 95 and 100

Treatment of intra-articular calcaneal fractures according to Palmer

e11

Figure 1 A 61-year-old patient who fell from a step-ladder. A: lateral X-ray of the left hindfoot: combined fracture with verticalization of the lateral joint fragment. The Bhler angle is 2 . B: X-ray at 10 months follow-up, after wire removal. Diffuse
demineralization, characteristic of reex sympathetic dystrophy syndrome. The Bhler is 22 , compared to a 26 healthy contralateral angle. C and D: X-ray at 22 months follow-up. Satisfactory bone mineralization. The Bhler angle is stable. Beginning subtalar
osteoarthritis. Restoration of the length and axis of the hindfoot. Clinical result is deemed fair because of pain with prolonged
walking.

points, good when between 80 and 94, fair when between

50 and 79, and poor when below 50 points. The presence of
pain, assessed on a visual analogic scale (VAS), the evaluation of the walking perimeter, subtalar and tibiotalar mobility, and deformity of the hindfoot were noted. Going back to
work and resuming sports activities, shoes and any orthotic
devices (insoles), and the subjective result (very satised,
satised, fairly satised, dissatised) were also reported.
The radiological workup at revision included frontal
Meary views of the ankle and lateral views of the hindfoot as
well as a retrotibial view. In the cases of unilateral fracture,
these images were completed by a comparative lateral view
of the healthy hindfoot.
The main parameter measured at the last follow-up visit
was the Bhler angle, allowing the quality of the anatomical reduction to be classied according to Babin et al. [18].
In addition, the existence of subtalar and calcaneocuboid
osteoarthritic deterioration, dened by greater than 50%
reduction in the joint spaces, was noted.

Results
Patients were evaluated at a mean follow-up of 23 6.8
months (range, 1238 months; median, 21 months). None
of the patients was lost to follow-up. One patient (one calcaneus) was excluded from the clinical evaluation at the last
follow-up because of unresolved paraplegia that occurred at
the same time as the calcaneal fracture.

Complications
Severe reex sympathetic dystrophy syndrome was observed
in one 61-year-old patient, who had been operated for a

combined fracture of the calcaneus following an accident

in the home. Surgery took place on the 11th day after the
accident because of phlyctenae. At follow-up at 22 months,
the problems had regressed after medical treatment and
physical therapy. The functional score was considered fair
because of intermittent pain appearing after prolonged
walking with beginning subtalar osteoarthritis (Fig. 1).
No complication on the operative site or on the iliac harvest site was observed. No deep infection was noted.

Revision surgeries
A talocalcaneal arthrodesis was performed on the left side
for advanced subtalar osteoarthritis in a patient who was
31-year-old at the time of the accident, when he fell 6 m
from scaffolding. The initial assessment showed a bilateral
combined fracture of the calcaneus. Both sides were operated on the day of the accident. There was no postoperative
complication. At the follow-up at 19 months, the functional
result was considered fair on the left, because of immediate
pain in the hindfoot when walking and a lateral conict. The
Bhler angle before arthrodesis was zero and the reduction
was considered poor according to Babin et al. [18]. No other
surgical revision was undertaken in this series.

Clinical results
At the last follow-up, the mean Kitaoka score was 74 24
out of 100 (range, 3498; median, 83). The functional result
was considered excellent in four cases (23.5%), good in
seven cases (41.2%), fair in three cases (17.6%), and poor in
three cases (17.6%). Occasional pain after prolonged walking (more than 1 h) was noted in 10 cases (59%). In three

e12
cases, there was nighttime and early morning pain in the
lateral malleolus area. Three patients took daily antalgics.
The walking perimeter was unlimited in 10 patients (59%).
Walking on uneven ground was difcult for ve patients
(29%). Of the 13 unilateral cases reviewed, subtalar mobility was greater than one-quarter in 12 cases and zero in
one case, compared to the healthy contralateral joint. The
mean dorsal exion of the ankle was 16 6.5 (range, 525 ;
median, 20 ). The mean plantar exion was 38 6.2 (range,
3045 ; median, 40 ). Six of seven patients (85%) who were
employed at the time of the accident had resumed their
occupation in an identical capacity. Three patients had to
wear orthotics. At the last follow-up, 10 hindfeet were
aligned, ve were moderately valgus (< 10 ), and one was
varus (10 ). Twelve patients (70.6%) reported they were satised or very satised with the intervention.

Radiological results
The mean postoperative Bhler angle was 23.4 10 (range,
540 ; median, 23 ). At the last follow-up, Bhlers angle
was 22.7 11 (range, 038 ; median, 22 ). According to
the Babin classication, the quality of the reduction was
deemed to be excellent (Fig. 2) in seven cases (39%), good
in six cases (33.3%), fair in two cases (11%), and poor in three
cases (16.6%) at the longest follow-up.
Of the 14 unilateral fractures, the nal Bhler angle was
at least equal to 85% of the healthy sides Bhler angle in 10
cases (71.4%). The mean postoperative Bhler angle value
was 27.5 (range, 1440 ) for type III fractures according to
Duparc and De La Cafniere [14] versus 19.5 (range, 530 )
for type IV fractures.

M. Di Schino et al.
A reduction in Bhlers angle between immediate postoperative images and images taken at the last follow-up
were noted in four cases (22%), with a mean 3 (range,
25 ) reduction, including the cases of revision with subtalar arthrodesis. Transferred to the entire series, the mean
loss in correction was 0.7 (range, 05 ). Table 1 shows the
differences in Bhler angle for each case and for each type of
fracture according to Uthza et al. [13] and the equivalents
in the Duparc [14] and Sanders et al. [15] classications.
Talocalcaneal osteoarthritis had appeared in four cases at
the last follow-up, including the case revised with subtalar
arthrodesis. These were three combined fractures and one
horizontal fracture according to Utheza et al. [13]. No calcaneocuboid osteoarthritis was noted. The radiological data
are summarized following Babins classication and compared to the functional data (Table 2). This table shows the
relation between the quality of the Bhler angle restoration
and the Kitaoka functional quality. However, a statistical
relation could not be established given the small sample
size.

Discussion
In his original 1948 publication, Palmer [12] described the
shearing mechanism of calcaneus intra-articular fractures,
following a fundamentally sagittal line. The technique,
described before Palmer by Lenormant and Wilmoth [19],
associated a retro- and lateral submalleolar approach, lowering the greater tuberosity, elevating the lateral thalamic
fragment and an impacted autograft. The clinical results
were favorable in 22 cases out of 23, with a follow-up of
six months to two years. Since this seminal publication, the

Figure 2 A 17-year-old patient after a fall from a 7 m height. A: lateral X-ray of the right hindfoot: combined fracture with the
Bhler angle measured at 14 . B: preoperative CT scan (frontal reconstruction): the fundamental line is median, separating the
joint surface into two main fragments. C: postoperative X-ray: restitution of the Bhler angle, measured at 36 versus 40 on the
healthy side. D: views at 18 months follow-up: the reduction was maintained over time. E: Absence of lateral overow and no
deviation of the hindfoot on the frontal Meary view of the ankle. F: Length and axis of the restored calcaneus, the functional score
was 96 out of 100 points (excellent result).

Treatment of intra-articular calcaneal fractures according to Palmer

e13

Table 1 Initial radiographic data according to Utheza et al. [13], Duparc and De La Cafniere [14], and Sanders et al. [15] and
progression of Bhlers angle.
Case

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15a
16a
17a
18a

Utheza et
al. [13]

Horizontal
Combined
Vertical
Combined
Combined
Combined
Vertical
Combined
Vertical
Combined
Vertical
Combined
Vertical
Horizontal
Horizontal
Combined
Combined
Combined

Duparc and De La
Cafniere [14]

III
III
III
IV
III
IV
III
IV
III
III
III
IV
III
IV
IV
IV
IV
IV

Sanders et
al. [15]

IIA
IIB
IIC
IIIBC
IIB
IIBC
IIC
IIIBC
IIC
IIB
IIC
IIIBC
IIC
IIIAB
IIIAB
IIIBC
IIIBC
IIIBC

Bhler angle
Preoperative

Postoperative

At longest
follow-up

Correction (%)

Loss

6
2
18
10
14
26
18
16
17
20
17
2
17
27
16
30
42
36

14
22
40
20
36
30
28
36
19
28
36
23
25
23
10
20
8
5

14
22
38
20
36
30
28
36
19
28
33
23
23
23
10
20
8
0

63
85
100
90
90
100
84
100
57
90
100
88
82
90

Correction expresses the correction of the Bhler angle in percentage compared to the healthy side. Loss expresses in degrees the
absolute value of the difference between the Bhler angle at the last follow-up and the angle measured on the immediate postoperative
X-rays.
a Bilateral cases.

results of the Palmer technique have been highly variable,

often disappointing, which has limited its dissemination
[20].
The natural course of intra-articular calcaneal fractures
has a poor prognosis [21]. The appearance of subtalar
osteoarthritis, more frequent after conservative treatment
[7], conditions the functional future of the hindfoot [22].
Studies comparing open treatment and conservative
treatment have shown the benet of surgical treatment in
terms of pain associated with walking, the rate of arthrodesis revision, and resuming work [7,2325]. The wide variety
of classications, techniques, and study criteria in the series
studied makes comparative analysis difcult. In particular, losses in radiological correction are not systematically
evaluated. Most authors favor xation with a rigid material, possibly associated with lling the subthalamic void

with spongy material [2629]. Plate xation osteosynthesis, sometimes associated with additional screw xation,
has consistently provided more than 85% good and excellent functional results [2,7,30,31]. Nevertheless, these good
results have not been reproduced by all authors. The inuence of the technique used is difcult to evaluate, but using
a medial approach combined with a lateral approach, independent of the quality of the reduction, seems to give less
satisfactory functional results [28]. Furthermore, the clinical results vary and the maintenance of the correction over
time is not systematically evaluated, making it impossible to
conclude that a spongy support is advantageous [7,28,32].
The use of less voluminous osteosynthesis material, without a graft, has given variable results. Khorbi et al. [33]
have recently analyzed the results of reduction and screw
xation in 35 intra-articular fractures of the calcaneus with

Table 2 Functional results according to Kitaoka et al. [17] in 17 cases compared to the quality of radiological reduction based
on Babin et al.[18].
Babin classication

Excellent (n = 7)
Good (n = 6
Fair (n = 2)
Poor (n = 2)

Mean Bhler angle

(range)

32.6 (2838)
21.2 (1923)
12 (10 and 14)
4 (8 and 0)

Mean Kitaoka score (range)

Pain (/40 points)

Function (/50 points)

Activity (/10 points)

Total (/100 points)

34.7
18.33
15
20

46
36.33
37
30

9.5
4.66
6
6

90
59
58
56

(8296)
(3481)
(34 and 82)
(48 and 64)

85.4
77
90
61
78
73
85
65
88.5a
100a
72a
65a
39
37
35
36
21
54
65
21
40
20
24
23
(CS)

(S)
(S)

(S)
(S)

205
22
44
157
33
33
83
46
31
15
35
18
No
No
Yes
Yes
No
No
Yes
Yes
No
No
No
Yes
Plate
Screws + staples
Plate/screws
Plate
Plate
Plate + screws
Plate
Plate
Plate + screws
Screws
Screws
Wires + screws
WL
L/C
L
M/L/C
WL
WL/M/C
WL
L
WL
PC
WL
WL
Bzes et al 1993 [2]
Stephenson 1993 [35]
Leung et al 1993 [7]
Zwipp et al. 1993 [28]
Laughlin et al 1994 [36]
Raymakers et al 1998 [37]
Thermann et al 1998 [30]
Stromsoe et al 1998 [32]
Besse et al 2000 [31]
Nehme et al. 2004 [34]
Khorbi et al 2006 [33]
Present study

Graft (type)
Fixation
Approach

The Functional results column shows the percentage of good to excellent functional results reported in the series. The Immediate complications column shows the number of
cutaneous and/or infectious complications and the number of cases requiring revision.
L: lateral; M: medial; C: combined (lateral + medial); PC: percutaneous; CS: cortico-spongeous; S: spongeous; NC: not communicated.
a According to Kitaoka et al. [17].

NC
NC
NC
NC
1
NC
NC
NC
5.2
0.15
3
0.67
35 (6)
6 (0)
0
20 (3)
4
0
NC
12 (3)
2
0
1 (0)
0

6
0
0
4
NC
2
NC
5
0
0
1
1

Adesis II (n)
Immediate complications
(revision)
Functional results
(good to exc) (%)
Mean follow-up
(months)
N
Technique
Author, date

Recent techniques and results from the literature.

Table 3

a mean follow-up of two years. Function was deemed good

or excellent in 72% of cases, but only 32% of cases had an
anatomical result considered to be good or very good. Furthermore, the correction was lost between the immediate
postoperative period and the last follow-up in 48% of the
cases, with a mean loss of 3 . The combination of a percutaneous technique with screw xation osteosynthesis and
follow-up of the reduction with arthroscopy gave encouraging results in a series studied by Nehme et al. [34]. In
the preliminary series reported by these authors, the functional results were good or excellent in all cases and the loss
of radiological correction was minimal at the 20th month
follow-up. Moreover, no cutaneous or infectious complications were observed. Table 3 summarizes the techniques and
the results of these recent series in the literature.
Systematic use of a supporting bone graft in treatment
of intra-articular calcaneal fractures has not been widely
studied and remains a subject of debate [38]. Jarvholm et
al. [5] systematically associated a cortical graft with screw
xation in a series of 20 intra-articular fractures followed
up at a mean ve years. Only 40% had no or only slight pain
and 60% of the patients had returned to work at the same
job. At the last follow-up, X-ray evaluation found a mean
Bhler angle of 1 .
In the series reported herein, systematic use of an
embedded structural graft, xed with wires and screws to
control the elevation in the intra-articular surface and the
transversal enlargement of the heel, gave good or excellent
reduction in 76% of the cases, excluding the failure revised
with arthrodesis. The immediate corrections obtained for
the fractures classied as type IV according to Duparc were
less (mean, 19.5 ) than those obtained for the type III fractures (27.5 ). The inuence of plantar cortex rupture may
be the cause in these cases. However, these were fractures
in which preoperative depression was the greatest: a mean
of 11 versus 3 for type III fractures. Furthermore, certain good anatomical results were obtained in this type of
fracture (cases 4, 6, 8, 12 Table 1). Duparcs type IV intraarticular fractures of the calcaneus were therefore not an
absolute contraindication to the Palmer technique. Reconstruction of the calcaneal plantar cortex using two wires is
an indispensable step in these cases.
The stability of the montage was considered satisfactory,
with a minimal loss of correction at the maximal follow-up.
The functional result was deemed satisfactory in two-thirds
of the cases and 85% of the patients employed at the time of
the fracture had resumed their work. The functional results
presented seemed less good than those reported in the reference series (Table 3). Although the surgical technique was
homogenous, the reduction deciencies reect the variable
experience on the part of the operators in the series of
injuries. In light of the retrospective analysis of the data,
restoring the Bhler angle was the essential functional prognostic factor, in agreement with the conclusions that have
been published elsewhere [39,40].
The absence of postoperative cutaneous complications is
a noteworthy observation in this series. This complication is
frequently observed in surgical treatment of intra-articular
fractures of the calcaneus in proportions varying from 3 to
28% [28,32,41]. Cutaneous complications are closely related
to infectious complications [2,42,43]. In addition, in onefourth of the cases, repeat interventions were required to

M. Di Schino et al.

Mean correction
loss

e14

Treatment of intra-articular calcaneal fractures according to Palmer

remove osteosynthesis material [2,32]. The data presented
by these authors did not allow for evaluating the inuence
of these surgeries on the permanence of the reduction. The
combined medial and lateral approaches used by Zwipp et
al. [28] and Stephenson [35] led to cutaneous complications in 15 and 27% of cases, respectively. The advantages
of osteosynthesis material that was ush with the bone was
underscored by Thordarson and Latteier [44], who found
no cutaneous complications in their series with a titanium
plate.
The epidemiological data associated with cutaneous
complications after intra-articular fracture of the calcaneus
(age, smoking habits, BMI, high-energy injury, associated
lesions) in the series reported herein were comparable to
those found in the literature [28,43]. Thus, given that there
is no bias specic to the cohort studied, the hypotheses
put forward to explain the absence of cutaneous complications result from the options chosen. Time to operation
is the rst one. Although some authors have reported that
time to surgery under seven days was detrimental to healing [43], on the contrary, like others [45], we recommend
surgery as soon as possible if the local conditions permit.
Next, a single wide approach that does not produce subcutaneous detachment or excessive tension on the edges
of the incision is another factor preserving the teguments
[28]. The use of embedded biological osteosynthesis with
compact subcutaneous material has allowed us to reduce
the tension on the scar. Finally, the relative simplicity of
this operative technique has resulted in short operative and
tourniquet times (mean, 58 min), another risk factor that
can cause cutaneous complications [43,45]. The results of
this small series, advocating maintenance and reduction as
well as the absence of cutaneous complications, can be compared to those reported by Thordarson and Bollinger [46],
who associated osteosynthesis with wires and lling with
osteoconductive cement.

[4]

[5]

[6]

[7]

[8]
[9]

[10]

[11]

[12]
[13]

[14]

[15]

[16]
[17]

Conclusion
Treatment of intra-articular fractures of the calcaneus
using a derived Palmer technique gave encouraging functional results conditioned by restoring the Bhler angle. Its
indications group intra-articular surface depressions corresponding to Duparcs types III and IV. The advantages of
this simple technique, whose execution is highly demanding,
reside in the absence of cutaneous and infectious complications and the stability of the reduction over time in this
preliminary series. These results must now be evaluated on
a larger series.

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