deur ef Orthopage Zouma Yol-6, No bs: Raves Pls Ltd, New York Review Article Intra-Articular Fractures of the Calcaneus: Present State of the Art Roy Sanders Orthopaedic Trauma Service and Tampa Orthopaedic Program, Tampa General Hospital, Tampa, Florida, U.S.A Key Words: Calcaneus—Open reduction-internal fixation—CT classification. Fractures of the os calcis were accurately de- scribed as early as 1843 by Maleaigne, but it was not until the 1930s that Bohler classified them and de- scribed their mechanism of injury (2,30). Since then, Essex-Lopresti, Warrick and Bremner, Socur and Remy, Burdeaux, and others have carefully an- alyzed this fracture (5,6,10,31,33,34,37). Despite extensive attempts, it has been recognized that re- sulis following treatment of comminuted intra- articular fractures of the os calcis have been far from what might be desired. At the present time, there remains no consensus regarding classi tion, indications for surgery, type of surgery, or postoperative treatment in the management of these. fractures (12). This review will attempt to clarify these issues, most notably the mechanism of injury, classification system based on computed tomogra- phy (CT) scanning, and results using a reproducible operative protocol via a lateral approach without bone grafting. MECHANISM OF INJURY The tuberosity of the calcaneus is located slightly lateral to the talus. As a result, when an axial load is applied to a foot whose heel is planted on a flat surface, the posterolateral edge of the talus frac- tures the calcaneus obliquely (Fig. 1). Two types of ‘Address correspondence and reprint requests to Dr. R. Sanders at Florida Orthopaedic Institute, 4175 E, Fowler Ave rue, Tampa, FL 33617-2011, U.S.A, 252 caleaneal fractures may occur, extra- or intra- articular, based on whether this fracture avoids or involves the posterior facet. Anteriorly, the fracture may exit laterally, usually at the angle of Gissane, but occasionally it may progress distally as far as the calcaneocuboid joint (5). Posteriorly, the pri- mary fracture line moves medially, separating the calcaneus into two main fragments: the sustentacu- lar or constant fragment, and the tuberosity frag- ment. Low-impact injuries result in simple non- or min- imally displaced fractures. Higher-energy injuries result in more comminuted fractures. If the force causing the fracture is purely axial, a secondary fracture line will appear beneath the facet, exiting posteriorly and resulting in a tongue-type fracture, as described by Essex-Lopresti (10). If the load is slightly more horizontal, the fracture line will exit just behind the posterior facet and resuit in a joint depression-type fracture (10). In these cases, the secondary fracture line may create a free lateral piece of posterior facet, separate from the tuberos- ity fragment. This latter piece is also known as the semilunar fragment, the comet fragment, or the su- perolateral fragment (5,31). Continued axial force results in a further defor- mation of the calcaneus. The talus with the constant sustentacular fragment continues its medial slide, shortening and widening the heel. Additionally, the posterolateral aspect of the talus will force the free lateral piece of the posterior facet down into the tuberosity fragment, rotating it as much as 90°. This results in an explosion of the lateral wall that mayINTRA-ARTICULAR CALCANEAL FRACTURES 253 FIG. 1. A: An axial load applied to the talus will result in a shear fracture line (primary fracture), separating the calca- rneus into two fragments: the constant or sustentacular trag- ‘ment (gray) and the tuberosity. B: Once complete, the calca: rneus will be wide and short, with displacement of the lateral wall, Note the collapse and rotation of the intra-articular ‘component (black), This is known as the superolateral frag- ment. (Computer-generated artwork courtesy of Mr, Christo- her Colton, Nottingham, England), extend as far anteriorly as the calcaneocuboid joint. Finally and most importantly, the collapsing lateral edge of the talus may further comminute the artic- ular edges, resulting in multiple osteochondral frac- ture fragments. RADIOLOGY Plain Films Plain films consist of a lateral projection of the hindfoot, an anteroposterior (AP) view of the foot, and a Harris axial heel view. The lateral projection will confirm a fracture of the calcaneus, a loss in height of the posterior facet, with a decrease in Bohler’s angle, and an increase in the critical angle of Gissane. The AP view of the foot may show a fracture into the calcaneocuboid joint and/or a lat- eral wall bulge. Otherwise, this view adds very little and in fact may be omitted in most settings. The Harris axial heel view allows visualization of the joint surface, as well as loss of height, increase in width, and angulation of the tuberosity fragment. It is extremely difficult to obtain this view in the acute setting because of pain and has been superseded by coronal CT. ‘Tomograms Tomograms are rarely indicated, as they add no additional information when CT scanning is avail- able, Deutsch et al. have pointed out that even when utilized, they may fail to show the extent of articular incongruity (9). Guyer et al. have analyzed. the dosimetry of the various modalities used to view calcaneal fractures radiographically (13). Biplanar 5 mm sections on CT only deliver a dose of 2.6 rad while tomography generates 20 rad. In the absence of CT scanning, the addition of Brodén’s views will usually suffice and are preferred to tomograms, both for visualization of the posterior facet and for decreased radiation to the patient. Brodén’s Views Brodén’s view is a reproducible means of viewing the articular surface of the posterior facet on plain films (4). This view, known as Brodén projection I, is obtained by placing the patient supine with the x-ray cassette placed under the leg and ankle. THE @. The pictures taken result in views that clearly show the posterior facet as it moves from posterior to anterior, with the 10° view showing the posterior portion of the facet and the 40° view showing the anterior portion. In this way, the surgeon can de- termine if the posterior facet is involved in the frac- ture and, if so, the amount of displacement and the degree of comminution. Additionally, this view can be used in the operating room to verify reduction of the articular surface. CAT Scanning CT scanning has revolutionized our understand- ing of these fractures and has allowed for consistent analysis of treatment results. The patient is posi- tioned in the supine position, with the hips and knees flexed. The feet are kept together with the plantar surface resting on the table (18). Both feet are routinely scanned for comparison. A lateral dig- ital radiograph (scout film) is obtained and the po- sition is modified until the coronal sections are truly perpendicular to the posterior facet. Once the scout film is correct, contiguous 3 mm thick sections are obtained from the posterior calcaneus to the navic- ular bone. The patient is then asked to extend the hips and knees, and a second scout film is obtained for transverse CT scanning. Once correctly posi- tioned, 3 mm thick sections are taken from the plan- Onhop Trauma, Vol.6, No. 2, 192254 R. SAND! tar surface to the talus. These two views, 90° to cach other, allow the surgeon a graphic representa- tion of the fractures and normal calcaneus. CLASSIFICATION Perhaps one reason why so much difficulty has been encountered in the treatment of fractures of the os calcis is the lack of understanding of the pa- thology of these fractures. Numerous classifica- tions of fractures of the os calcis have been created, icluding those of Bohler, Palmer, Widen, Rowe, Warrick and Bremner, Lindsay and Dewar, and Es- sex-Lopresti (2,10,17,23,26,37,38). All have been frustrated by limitations in radiographic techniques. Because similar fracture patterns were not ana- lyzed, similar treatment regimens resulted in vary- ing degrees of success. Asa result, the author de- veloped a CT scan classification based on the num; ber and location of articular fracture fragments. Begun in 1986, this system is a natural progression R SE \W CH is J Orthop Trauma, Vol.6, No. 2, 192 &B BS ie RS of the classification by Socur and Remy, and has been applied prospectively to over 250 fractures (27,31) (Fig. 2) I These two lines separate the posterior facet of the calcaneus into three potential pieces: a medial, central, and lateral column, A third fracture line C, corresponding to the medial edge of the posterior facet of the talus, separates the posterior facet from the sustentaculum and results in a total of four potential pieces. The lines are named A, B, and C, from lateral to medial, because as the fracture line moves medially, intraoperative visualization of the joint becomes more difficult, and the ability to obtain an anatomic reduction de- creases, All nondisplaced articular fractures, irrespective of the number of fracture lines, are considered type. FIG. 2. CT scan classification of intra-articular calcaneal fractures. It is Important that the co ronal section analyzed includes the widest point of the articular surface, i.,, it must include the sustentaculum,INTRA-ARTICULAR CALCANEAL FRACTURE: 1 fractures (Fig. 3). These benefit from nonopera- tive intervention unless an extra-articular compo- nent exists that is severely displaced. Type I] frac- tures are two-part fractures of the posterior facet, similar in appearance to a split fracture of the tibial plateau (Fig. 4). Three types (IIA, IB, and 1IC) exist, based on the location of the primary fracture line. Type III fractures are three-part fractures that, feature a centrally depressed fragment, similar to a split depressed tibial plateau or die-punch distal ra- dial fracture (Fig. 5). Types include IAB, IAC. and IIIBC. Type IV fractures, or four-part articular fractures, are highly comminuted (Fig. 6). Occa- sionally, more than four articular fragments exist TREATMENT Presently, three broad categories for the tr ment of acute displaced intra-articular caleaneal fractures exist: (a) nonoperative treatment, (b) open, reduction and internal fixation, and (c) primary or delayed arthrodesis. te Nonoperative Treatment ‘The author believes that nonoperative treatment of displaced intra-articular fractures of the calea- neus offers little chance of return to normal func- tion. Of concer is the fact that a reduction of the articular surface is never obtained. If casting is em: ployed, remaining subtalar motion is ultimately lost because of adhesions. Additionally, as the lateral wall cannot be accurately reduced, impingement and binding of the peroneal tendons is a relatively constant finding. Nonetheless, there are specific in- dications for nonoperative treatment: (a) nondi FIG. 3, CT scan of a type | fracture, The articular surface is, nondispiaced in both views. 255 placed fractures, (b) open fractures or fractures in patients with life-threatening injuries that preclude early intervention, (c) soft-tissue compromises, such as blistering, that prevent surgery, (d) severe peripheral vascular disease or diabetes, and (e) se vere infirmity. Operative Treatment Using a Lateral Approach Timing of Surgery Surgery ideally should be performed within the first 3 weeks of injury to prevent difficulties with reduction secondary to early consolidation of the fracture. Surgery should not be attempted until af- ter swelling in the foot and ankle has decreased sig- nificantly (14). This is crucial in order to avoid the complications of wound breakdown postopera- tively. Because this may take 7 to 14 days, imme- diate ice and elevation on a Bohler-Braun frame is required. If this is not accomplished, the window of time for fixation may be lost One way to determine if the swelling has de- creased significantly is to use the “wrinkle test.” The patient is asked to evert and dorsiflex the foot the observer determines if the skin creases wrinkle. Wrinkling plus the complete absence of pitting edema along the proposed lateral incision site are excellent indicators of decreased edema, Blistering of the skin can be a difficult problem. The author bursts all blisters sterilely and cover them with Tegaderm (3M Medical-Surgical Divi- sion, St. Paul, MN, U.S.A.) in an attempt to have the skin ready for surgery. Prolonged blistering, however, will preclude surgical intervention and may force the patient with an otherwise simple frac- ture to be treated nonoperatively. Positioning The patient is placed in the lateral decubitus po- sition on a translucent table or cardiac pacemaker insertion board (pacer board) so that fluoroscopy may be used intraoperatively. After exsanguina- tion, the tourniquet is inflated to 300 mm Hg. A bolster under the medial malleolus allows the heel to fall into slight inversion, thus improving visual- ization of the subtalar joint Incision Opinions vary as to the best incision. Both lateral and medial approaches have advocates and often both are needed for an adequate reconstruction. A J Orthop Trauma, Vol 6, No. 2, 1992256 R. SANDERS FIG. 4. CT scan of type Il fractures: IIA (A), IIB (B), IIC (C)—note the empty facet sign, i. the entire facet is missing. Further analysis of the CT scan identified the facet posterior and medial to the tuberosity lateral incision is used more frequently, but contro- versies over specific techniques exist even among those who agree on this approach. There is dis: agreement on whether the incision should be started above or below the peroneal tendon sheath, whether it should be short to anticipate a second J Orthop Trauma, Vol. 6, No. 2, 1992 medial incision or extensile. Surgeons who dislike operating through compromised tissue may prefer the Ollier incision advocated by Ross and Sowerby (25). Conversely, surgeons who work in trauma centers and who are familiar with handling acutely injured soft tissues prefer the extensile right-angledINTRA-ARTICULAR CALCANEAL FRACTURES 257 FIG. 8. CT scan of type Ill fractures: IIIAB (A), IAC (B), IIIBC (C), approach described by Zwipp and colleagues (39 41) The calcaneus is approached through an extensile right-angled lateral incision (Fig. 7A). In this ap- proach, the vertical limb is placed just in front of the heel cord and reaches down to the junction of the plantar and lateral skin. It is then carried forward in, the horizontal limb approximately to the area of the calcaneocuboid joint. The incision is carried straight down to bone at its angle and then devel- oped in such a manner as to allow a thick flap to be lifted from the subperiosteal surface. This approach minimizes the sequelae of peroneal tendinitis and devascularization of the anterior skin flap, as well as preserving the sural nerve, which is entirely within the flap (11,15). ‘The peroneal tendon sheath is then freed subperi- osteally from the lateral malleolus until it can be shifted anteriorly over the malleolus as one unit The sheath is held anterior to the fibula by the use of two K-wires, one in the fibula and one in the talus (Fig. 7B). This “no-touch” technique obviates the need for manual retraction of the peroneal tendons and the anterior skin flap. Finally, the incision may J Orthop Trauma, Vol.6, No. 2, 1992258 R. SANDERS FIG, 6. CT scan of a type IV fracture. Note the complexity of this fracture, suggesting a poorer prognosis. be taken as far proximally as needed, allowing the fixation of any associated ankle fractures simulta- neously (11,15). Joint Reduction If not already taken as part of the skin flap, the caleaneofibular ligament is identified and sharply cut off the calcaneus and retracted anteriorly. The lateral wall is subperiosteally cleaned of soft tissue and is gently pried laterally to expose the articular fracture fragments. After clot removal, the poste: rior facet is evaluated. The depressed fracture frag- ment is first rotated out from within the body of the calcaneus. This immediately decompresses the lat- eral wall. After identification of all remaining artic- ular fracture fragments, preliminary reduction of the facet is obtained using K-wires. In order to align the fragments properly with respect to rotation, vi- sualization of the anterior and posterior aspects of the facet is necessary; this may require excision of the fat immediately behind the posterior facet. Gis- sane’s angle is carefully evaluated, as this is the key to the anterior reduction. As the articular fracture line moves medially, or if several articular fracture lines exist, visualization of joint reduction becomes exceedingly difficult. This is primarily due to the fact that once the lateral articular surface is reduced, the joint cannot be ad- equately opened to visualize the reduction. There- fore, intraoperative fluoroscopic Brodén's views are obtained to aid in this assessment (28) (Fig. 8) ‘The fluoroscope can be left on for a sweep of the joint when reduction is believed to be anatomic. When the reduction is satisfactory, K-wires are ex- changed for 3.5 mm lag screws that are angled to J Orthop Traum, Vol. 6, No.2. 1992 obtain purchase into the constant sustentacular fragment. Washers should be employed as needed (is), Reduction of the Body Attention is then turned to reduction of the tuber- osity fragment. Through the lateral approach, this can most casily be accomplished by placing a small periosteal elevator across the fracture line, and le- vering the body against the medial edge of the sus tentacular fragment (the spike), thereby correcting, the length, width, and “varus.” An axial spike or transverse traction pin is placed into the tuberosity fragment to assist reduction if necessary (1,15,20, 23,31). This maneuver to correct body alignment may need to be performed before joint reduction, if varus tilt of the lateral fragment of the posterior facet exists and is preventing articular surface re- duction. A Harris heel view is obtained intraopera- tively. either by fluoroscopy or plain film to assess reduction. Once satisfactory, a small plate is used to reduce the body and buttress the lateral wall Intraoperative fluoroscopic lateral radiographs are also obtained to assess height and angulation. The choice of plate is based on the complexity of the fracture and personal preference. Some sur- geons recommend the use of a 3.5 mm reconstruc- tion plate. Leung and others recommend the use of anterior cervical or H plates to secure the lateral wall (16). Bezes et al. suggested a one-third tubular plates alone or in combination, when the facet frag- ments need to be secured to the body (1). The au- thor has had good success using a low profile H plate modified with a Y limb, after Letournel (15), to achieve this.INTRA-ARTICULAR CALCANEAL FRACTURES 259 Controversy exists about grafting the defect that remains after the superolateral fragment of the pos- terior facet has been lifted from the body. Grafting is not always necessary and Letournel does not use it routinely (15). The morbidity associated with grafting must be balanced against the possibility of complications, and the decision to graft remains a personal preference. Closure and Postoperative Management If reduction is acceptable, closure is performed over a drain and final films are taken. The leg is placed in a bulky Jones dressing. The drain is re- moved on postoperative day 2 and the dressing on day 3. A removable short leg cast is then placed, and subtalar motion begun. This is the most impor- ‘A; The extensile right-angled lateral ap- 0 the calcaneus, B: The “no-touch tech- nique” using K-wires to retract the skin flap. Lat- ‘eral (C) and coronal (D) views of reduction ma- neuvers to restore articular congruity and calcaneal shape, Two screws are needed to pre- vent rotation of the superolateral fragment. (Re~ produced with permission from Jahss M. Disor- ders of the Foot and Ankle, second edition. Phil- adelphia, W.B. Saunders and Co., 1991) tant aspect of the patient's postoperative care. Stephenson (34) compared the results of Palmer (23), and McReynolds (21) to his own series and showed that early motion resulted in significantly improved subtalar motion. ‘A repeat CT scan in both the coronal and trans- verse planes is then obtained to evaluate the reduc- tion, Sutures should be left in place for 3 weeks to minimize the chance of wound dehiscence. The pa- tient is kept non-weight bearing for 8 weeks with progressive weight bearing begun after that. Full weight bearing is allowed by 3 months (Fig. 9) Primary Fusion A routine primary fusion of the subtalar joint is not advisable after calcaneal fracture, because the J Orthop Trauma, Vol. 6, No.2, 1992260 R. SANDERS fusion only addresses subtalar pain. Primary arth- rodesis alone does not solve the problem of a wid- ened heel, peroneal entrapment or dislocation, a dorsiflexed talus, malleolar impingement caused by flattening of the heel, or the overall cosmetic prob- lem, which is especially distressing to women. Re~ cently, the author has combined an anatomic resto- ration of the calcaneus using internal fixation with a primary fusion in certain cases. In this manner, all problems associated with these fractures may be addressed simultaneously. Early experience in ten type IV fractures treated this way has been encour- aging, with all ten patients returning to work within 6 months of injury. COMPLICATIONS ‘Wound Dehiscence/Calcaneal Osteomyelitis Should the wound be impossible to close at sur- gery, a delayed primary closure may be attempted. Skin grafting alone in this region has been unsuc- cessful, and in this situation a free tissue transfer will be required. Postoperatively, the wound may dehisce as late as 4 weeks, usually at the angle of the incision. Daily whirlpool treatments with wet to dry dressing changes should be employed. Again, if this is unsuccessful, a free flap must be employed to salvage the extremity. ‘Once an infection has occurred, repeat debride- ments must be performed. If the infection is super- ficial, the plate and screws may be retained. After the wound bed is deemed clean, a free tissue trans fer combined with 6 weeks of intravenous antibiot- ics is used. If osteomyelitis exists, the hardware must be removed together with all necrotic and in- J Onhop Trauma, Vol. 6, No.2, 1992 FIG, 8. Intraoperative Broden’s view. This view will allow one to assess the subtal tion even when direct visualize tion is impossible (large ar- rows—subtalar joint; small ver- tical arrow—articular fracture line), fected bone. After repeated debridements and 6 weeks of culture-specific antibiotics, salvage, fu- sion, or amputation based on the amount of remain- ing calcaneus is performed. Subtalar Arthritis Most commonly the result of a poorly reduced joint, subtalar arthritis may occur even in the pres- ence of a normal radiograph and arthrogram, sec- ‘ondary to cartilage necrosis at the time of injury. In either case, the patient should be initially treated by nonoperative means. Often, activity change, shoe modifications, and anti-inflammatory medications may be successfully employed. If these modalities are unsuccessful, a subtalar injection should verify the location of the pain. If the injection is success- ful, subtalar or triple arthrodesis should be contem- plated. Lateral Impingement Syndrome Most commonly a residual of nonoperative treat- ment, the lateral wall may impinge either the pero- neal tendons or the fibula (3,32). The problem may. be consistently and successfully treated by lateral wall resection, or removal of hardware, if impinge- ‘ment occurs postoperativel ignosis is eas- ily made clinically by palpation but can also be clearly seen on CT scan. Sural Neuritis, Because the sural nerve travels with the peroneal tendons, it is often stretched, contused, or cut dur- ing surgery using the standard lateral Kocher inci-INTRA-ARTICULAR CALCANEAL FRACTURI sion. The most consistent solution to this problem is, to use the extensile approach, centered well away from the fibula, as previously described (41). Since employing this incision, we have had no instances of sural neuritis or neuromas. Should a symptom- atic neuroma develop, however, proximal resection, is advised Shoe Problems One of the benefits of operative intervention is improvement in heel height, width, and length. At the very least, this will allow the patient to wear normal or slightly modified shoes. In patients with severely comminuted calcaneal fractures treated nonoperatively, a combination of problems includ- ing subtalar arthritis, peroneal impingement, and shortening and widening of the heel may occur Carr et al. have recently noted that these patients also have significant problems with dorsiflexion be- cause of talar neck/tibial plafond impingement due to talar collapse into the calcaneal body (7). In these cases, a subtalar bone block fusion is indicated. RESULTS ‘The literature is filled with accounts expounding the merits of vatious modalities in the treatment of intra-articular calcaneal fractures. Simpson et al. reviewed the 62 largest series until 1983 (30). The reader is cautioned against making conclusions based on this information. Simple nondisplaced fractures will do well and, conversely, highly com- minuted fractures will do poorly, regardless of the treatment employed. Clearly, if nonoperative meth- ods are used in highly displaced fractures and op- erative methods are reserved for minimally dis placed fractures, the results would favor operative reduction. Finally, because classification schemes and postoperative assessment were not consistent, difficulty arises in understanding what these series represented. Thus, the entire body of literature be- fore CT scanning was available is ambiguous at best (15,24,25). Since 1983, several series using more modern methods have been published. Stephenson reported on 22 displaced intra-articular calcaneal fractures using medial and lateral approaches, with 77% g0od-excellent results, and return to work within 6 months in all but one patient (34). Leung et al. had similar findings with 64 displaced intra-articular cal- caneal fractures (16). Although follow-up was only 10.6 months, over 80% of the patients returned to work within 6 months. 261 PROGNOSTIC CLASSIFICATIONS Miiller et al., in their classification of fractures, addressed the question of prognosis after an artic ular fracture (22). The more comminuted an articu- lar fracture was, the worse the outcome expected. Until the advent of CT scanning, however, evalua- tion of the subtalar joint and hence a prognostic classification for intra-articular calcaneal fractures was not possible, CT scan classifications of intra- articular fractures of the calcaneus must be prog- nostic, and aid the surgeon in determining both treatment and outcome. Nonoperative Treatment Crosby and Fitzgibbons evaluated the result nonoperative treatment using a CT scan classi tion based on the fracture pattern involving the pos- terior facet (8). They classified small or nondis- placed fractures as type I, displaced fractures as type II, and comminuted fractures as type III. Their series included 13 type I, 10 type Il, and 7 type TIL fractures. Fractures were treated with a variety of closed methods, depending on the individual sur- geon’s preference. Based on this classification, they were able to predict which fractures did well, and which did poorly using nonoperative treatment. They concluded that all type I and some type II fractures did well, but all type III fractures did poorly with closed treatment, Unfortunately, as ‘Sangeorzan and others have pointed out, there were numerous questions raised concerning treatment methods, positioning of the foot during CT scan- ning, and analysis of results using a new and un- proven rating scale (29,36). In general, however, this classification does appear to anti pected outcome using nonoperative techniques Operative Treatment Sanders et al. reported on 132 displaced, intra- articular calcaneal fractures (types I-IV) using their CT scan classification with follow-up in 120 cases (range of 12-56 months, average of 29.3 months) (27). Alll fractures were treated using a lat- eral approach, lag screw fixation of the joint, H-plate fixation of the body, and no bone grafting. All patients had preoperative, postoperative, and 1 year follow-up CT scans. Clinical outcome was based on the Maryland Food Score. Reduction in J Orthop Trauma, Vol. 6, No.2, 1992262 heel height, length, and width were 98, 100, and 110% of normal, respectively, regardless of fracture type. Béhler’s and Gissane’s angle were reduced within 5° of normal in all but three cases. In type II fractures, 68 of 79 fractures (86%) had a radio- graphic anatomic reduction of the articular surface as verified by follow-up CT scan. There were ten. near-anatomic articular reductions, and one ap- proximate reduction. The clinical outcome in 58 (73%) fractures was graded as good or excellent Eight (10%) fractures had a fair result and 13 (17%) were failures, with 10 of 21 requiring subtalar fu- sion. In these cases, arthrogram, CT scan, and in- J Orthop Trauma, Vol. 6, No.2, 1992 R. SANDERS FIG. 9. Case of bilateral intra-articular fracture treated with ORIF using a lateral approach and no graft. Lateral views (A); 30° degree Broden views (B); Harris neal views (C); two- dimensional CT scan coronal views (D), showing bilateral type IIB fractures; two-dimensional CT scan transverse views (6), note extension into the calcaneocuboid joint, spection of the joint at the time of isolated subtalar fusion verified an anatomically reduced articular surface with damaged cartilage In type III fractures, there were 18/30 (60%) ra- diographically verified anatomic, 8 near-anatomic, and 4 approximate reductions. Clinically, there were 21 (70%) excellent-good results, 3 (10%) fai results, and 6 (20%) failures. Seven fractures ulti- mately required a subtalar fusion: four of these were in fractures that had been anatomically re- duced. In the type IV fractures, there were no (0%) anatomic, three (27%) near-anatomic, two (18%) approximate, and six (54%) complete failures of re-INTRA-ARTICULAR CALCANEAL FRACTURES 263 FIG. 9. cont. Three-dimensional CT scan of left foot (F); and right foot (G); immediate postoperative lateral views showing eduction of joints using two lag screws and a long H plate (H); Harris heel views postoperatively (I); immediate postoperative coronal (J) and transverse (K) Ct scan verifying anatomic reduction of the joint surface and shape of the calcaneus. 1 year follow-up coronal (L) and transverse (M) CT scan showing no change in reduction and no evidence of subtalar arthrosis. The patient returned to full duty as a roofer 5 months postoperatively with no complaints other than morning stiffness. J Orthop Trauma, Vol. 6, No.2, 1992264 R. SANDERS duction. Clinically, there was one (9%) excellent- good result, two fair (18%) results, and eight (73%) complete failures. The one good and two fair results were in patients with near-anatomic reductions When results were compared by year, a distinct learning curve appeared (Fig. 10). Worse results oc- curred at the start of the series while the number of good-excellent results improved each successive year. When these data were further analyzed with respect to fracture type and year, it appeared that type Il fractures were easier to fix than type III fractures. With time, even type HII results im- proved. Despite a better outcome for type Il and Ill fractures over time, however, the results of opera- tive intervention in type IV fractures were not im- proved upon, even after 4 years of experience. DISCUSSION Previously, many authors noted the type of frac: ture and the number of fragments present, the scheme of Essex-Lopresti being the most widely used (10,34,35). None of these authors focused on the joint reduction itself, being more concerned with restoration of overall shape and correction of Bohler’s angle to prevent disability. As a result, McReynold’s and others stressed the importance of ‘a medial approach to reconstruct the shape of the extra-articular calcaneal body (5,21). Unfortu- nately, this approach results in an indirect and often, incomplete reduction of the joint surface. As a re- sult, Stephenson employed a medial approach for body reduction, and a lateral approach for joint re- duction, The most recent series all use a lateral approach (1,16,41). Reduction of the body with reconstitution of height, width, and length is consistently repro- 7s 50 . all ° "a7 196815891990, EXCELLENT - GOOD FIG. 10, The learning curve for calcaneal fractures. Results steadily improve with the surgeon's ability to treat these frac tures operatively. This ability did not extend to type IV frac- tures. J Orthop Trauma, Vol.6, No. 2, 1992 ducible, irrespective of the amount of comminution, Joint reduction, when technically possible, is easy through the lateral approach as well. It appears, therefore, that a medial approach is only rarely needed, In our series, the majority of type II and type III fractures had an anatomically reduced posterior facet. Despite this, 14 anatomically reduced frac- tures ultimately required a subtalar fusion. It ap- pears, therefore, that although an anatomic articu- lar reduction is necessary for a good outcome, it cannot guarantee it, probably due to cartilage ne- crosis from the original injury. The use of bone grafting is still controversial Palmer was unhappy with contemporary internal fixation techniques and therefore suggested bone graft to hold up the articular surface (23). LeTour- nel, using internal fixation, suggested that bone, grafting was unnecessary because lag screws were. able to hold the articular surface together (15). ‘Stephenson used no bone grafting and only had one late collapse, while Leung used bone grafting in all cases and felt it was needed (16,34). In our series, bone grafting was not employed and in no case was there a subsequent loss of articular reduction. Con- sequently, the author believes there is little need for bone grafting, and in fact the graft can block artic- ular reduction (19,34), Our protocol eliminated as many variables as possible to determine if the articular fracture clas- sification was prognostic. Interestingly, an unfore- seen variable appeared, a surgeon-dependent learn- ing curve. The curve appears to require between 35-50 cases or roughly 2 years, before results can become fairly predictable for type II and III frac- tures. Type IV fractures are so severe that even the most experienced surgeon may find it difficult to piece these fractures together. Knowing this in ad- vance will allow the surgeon and patient to prepare y of a primary fusion. CONCLUSIONS Displaced intra-articular fractures of the calea- neus require anatomic reduction with stable internal fixation to maximize the chances for good joint function and restoration of normal hind foot shape. The recent literature indicates that open redui and internal fixation within 10 days of injury yield the most satisfactory results. Treatment should be tailored to the “personality” of the fracture. This is, best evaluated using a prognostic fracture classifi-INTRA-ARTICULAR CALCANEAL FRACTURES 265 cation. CT scanning is the only accurate method of analyzing this complex fracture and therefore only a CT scan classification can be prognostic. Using such a classification, the following conclusions can be reached. ‘The majority of intra-articular caleaneal fractures are (ype II fractures and are amenable to operative intervention. Good results and return to work can be expected. Type III fractures are less frequent and have a worse prognosis. Patients should be counseled that disability, and the possible need for a late subtalar fusion, may occur. Type IV fractures are rare injuries. Operative intervention is sug- gested in these fractures, if only to restore calcaneal shape, and if the joint cannot be restored, primary arthrodesis should be considered. With operative intervention, a learning curve exists, and the sur- geon should expect significant improvement after approximately 35 cases or 2 years. REFERENCES Bezes H, Massart P, Fourquet JP. Die Osteosynthese der Caleaneus-Impressionsfraktur. Unfallheildunde 87:363-368,, 1984. 2. Babler L. Diagnosis, pathology and treatment of fractures of the os caleis. J Bone Joint Surg 13-75-89, 1931, 3. Braly WG, Bishop JO, Tullos HS. Lateral decompression for malunited os calcis fractures. Foot Ankle 6:90-96, 1985, 4, Broden B. Roentgen examination of the subtaloid joint in fractures of the caleaneus. Acta Radiol 31:85-91, 1949. 5. Burdeaux BD. Reduction of calcaneal fractures by the ‘McReynolds medial approach technique and its experimen- tal basis. Clin Orthop 177:87-103, 1983, 6, Carr JB, Hamilton JJ, Bear LS, Experimental intra-articular ‘calcaneal fractures: Anatomie basis for a new classification, Foot Ankle 10:81-817, 1989, 7. Carr JB, Hansen ST, Benirschke SK. Subtalar distraction bone block fusion for late complications of os calcis frac: tures. Foot Ankle 9:81-86, 1988, 8. Crosby LA, Fitzgibbons T. Computerized tomography scan- hing of acute intra-articular fractures of the calcaneus. J Bone Joint Surg (Am) 72:852-859, 1990, 9. Deutsch A, Resnick D, Campbell G. Computed tomography ‘and bone scintigraphy in the evaluation of tarsal coalition Radiology 144:137-140, 1982 10. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os caleis. Br J Surg 39:395-419,, 1952, 11. Fernandez DL. Transarticular fracture of the caleaneus, Arch Orthop Trauma Surg 103:195-200, 1984. 12, Giachino AA, Unthoft HK. Intra-articular fractures of the calcaneus. J Hone Joint Surg [Am] 71:784-787, 1989, 13, Guyer BH, Levinsohn EM, Fredrickson BE, Bailey GL, Formikell M. Computed tomography of calcaneal fractures Anatomy, pathology, dosimetry, and clinical relevance. AJR 145:911-919, 1985 14, Harding D, Waddell JP. Open reduction in depressed frac- tures of the os caleis. Clin Orthop 199:124-131, 1985, 15. LeTournel E. Open reduction and internal fixation of calea- neal fractures. In: Topics in Orthopedic Surgery, ed by P Spiegel. Baltimore, Aspen Publishers, 1984, pp 173-192. 16. Leung K, Chan W, Shen W, Pak P, So W, Leung P, Oper~ ative treatment of intraarticular fractures of the os caleis. J Orthop Trauma 3:232-240, 1989. 17, Lindsay WRN, Dewar FP. Fractures of the os caleis. Am J Surg 95:555-S76, 1958, 18. Martinez S, Herzenberg JE, Apple JS. Computed tomogra- phy of the hindfoot. Orthop Clin North Am 16:481-496, 1985. 19. Maxfield JE. Os calcis fractures: Treatment by open redue- tion. Clin Orthop 30:91-99, 1968. 20. Maxfield JE, MeDermott FJ. Experiences with the Palmer ‘open reduction of fractures of the calcaneus. J Bone Joint Surg [Am] 37:99-106, 1955, 21. McReynolds 1S. The case for operative treatment of frac- tures of the os caleis. In: Controversies in Orthopedic Sur- gery, ed by RE Leach, FT Hoaglund, EY Riseborough, Phil- Adelphia, W. B. Saunders, 1982, pp 232-254, 22. Muller ME, Nazarian S,'Koch P. Classification AO des Fractures. Berlin, Springer-Verlag, 1987. 23. Palmer I. The mechanism and treatment of fractures of the calcaneus. J Bone Joint Surg (Am) 30:2-8, 1948. 24. Pennal GF, Yadov MP. Operative treatment of comminuted fractures of the os calcis. Clin Orthop 4:197-211, 1973 25. Ross SDK, Sowerby MRR. The operative treatment of frac- lures of the os ealeis. Clin Orthop 199:132-143, 1985. 26. Rowe CR, Sakellarides H, Freeman P, Sorbie C. Fractures ‘of os calcis—a long term follow-up study of one hundred Torty-six patients, JAMA 184:920-923, 1963. 27. Sanders R, Fortin P, Dipasquale T, Walling AK. Operative ‘weatment in 120 displaced intra-articular caleaneal fractures: Results using a prognostic CAT scan classification. Clin Or thop (in press). 28. Sanders RW, Dipasquale T. Intra-operative Broden's views in the operative treatment of calcaneal fractures {Abstract Orthop Trans 13:537, 1989, Sangeorzan BJ. Letter to the Eulitor. J Bone Joint Surg (Amt 73:1430-1431, 1991 30, Simpson LA, Schuiak DA, Spiegel PG. Intraarticular frac- tures of the calcaneus: A review. Contemp Orthop 6:19-28, 1983. 31. Soeur R, Remy R. Fractures of the calcaneus with displace- ‘ment of the thalamic portion. J Bone Joint Surg (Br) S7:413— 421, 1995, 32. St. C. Ibister JP. Caleaneo-fibular abutment following crush fracture of the calcaneus. J Bone Joint Surg [Br] 56:274-278,, 1974. 33. Stephenson IR. Displaced fractures of the os calcs involving the subtalar joint: The key role of the superomedial frag: ment. Foot Ankle 4:91-101, 1983. 34. Stephenson JR. Treatment of displaced intra-articular frac- {ures of the calcaneus using medial and lateral approaches, internal fixation, and early motion, J Bone Joint Surg (Ar) (69:115-130, 1987. 35. Thoren O. Os caleis fractures. Acta Orthop Scand suppl 70, 1964, 36. Thifftt PD, Gregg PI. Letter to the Editor. J Bone Joint Surg [Am] 73:1429-1430, 1991 31. Warrick CK, Bremner AE. Fractures of the caleaneum. J Bone Joint Surg [Br] 35:33-45, 1953. 38. Widen A. Fractures ofthe calcaneus, Acta Chir Sand suppl 188, 1954, 39. Zwipp H. Tscherne H. Calcaneusfracturen: Offene Reposi- tion und mediale Stabilisierung. Unfallheilkunde 85:494-498,, 1982, 40. Zwipp H, Tscheme H, Wulker N. Osteosynthese Dislo- Zierter Intraartikularer Caleaneustrakturen. Unfalichirurgie 91:507-515, 1988. 41. Zwipp H, Tscherne H, Wulker N, Grote R. Der intraartiku- lare Fersenbeinbruch. Unfalichirurgie 92:117-129, 1989, 8 J Orthop Trauma, Vol. 6, No.2, 1992