Early ORIF intervention for calcaneal fractures: a viable treatment option

Aggressive soft tissue management allowed operation as early as 3 days postinjury.

Issue: February 2007

Used in the appropriate patients, early operative intervention for calcaneal fractures may help avoid soft tissue contracture, lead to early joint motion and achieve a more accurate reduction, according to an Illinois investigator.

Because early open reduction and internal fixation (ORIF) of calcaneal fractures has been associated with wound complications, surgeons typically delay surgery for about 1 to 2 weeks to allow the soft tissues to heal.

"Soft tissue complications are probably the most concerning early complication that can occur after ORIF of a calcaneus fracture," Telly Psaradellis, MD, told Orthopedics Today. "The skin there is very tenuous, it doesn't have a relatively good blood supply, and these injuries tend to be high-energy associated with a lot of swelling. The biggest concern early on is wound problems: wound dehiscence, wound infections and so forth."

Decision based on convention

However, "This 1- to 2-week time period is arbitrary based primarily on convention rather than concrete scientific data," Psaradellis said at the Orthopaedic Trauma Association 22nd Annual Meeting. Psaradellis is currently an orthopedic traumatologist at Fox Valley Orthopedic Institute in Geneva, Ill. At the time of this investigation, he was in his trauma fellowship at OrthoIndy in Indiana.

Psaradellis and his co-investigators performed preliminary research on whether early surgery — those performed within 5 days of injury — affected the complication rate or the quality of reduction.

To operate this early they used an aggressive soft tissue management protocol, which involved admitting patients with calcaneal fractures when they presented at the emergency room, placing them on bed rest and instructing them to elevate the injured leg.

The investigators used a compression dressing and a Cryocuff (Aircast) on the leg. They checked the skin daily for resolution of soft tissue swelling.

"We wouldn't operate if the skin wasn't ready, but we were finding that it was ready at sometimes day 3, day 4, day 5," Psaradellis told Orthopedics Today. "We wouldn't have to wait the full 2 weeks."

Their study included 96 patients (80 men, average age 39.7 years) with 101 calcaneus fractures treated by a single surgeon between 1995 and 2005. Injury mechanisms were as follows: falls from height (69), motor vehicle accidents (24), low-energy accidents (7) and motorcycle accidents (1). Patients operated on within 5 days of injury were included in the early operative group: all others were assigned to the delayed group.

Analyzing with Bohler's angle

The investigators analyzed the quality of reduction with Bohler's angle and posterior facet step-off on all available postoperative lateral and Broden's view radiographs, according to their abstract. They used Yates-corrected chi-squared analysis and Student's t test to analyze complication rates and quality of reduction.

The researchers found no differences in the complication rates (P=.511), Bohler's angle (P=.20) or posterior facet step-off (P=.36) between the two groups, according to the abstract.

Twelve patients in the early group had at least one complication; 20 patients had at least one complication in the delayed group, Psaradellis said during his presentation. Complications included epidermolysis, drainage, hematoma, deep infection and osteomyelitis. There were no secondary operations in the early group and four in the delayed group.

Mean time to surgery was 3.7 days in the early group and 10.5 in the delayed group, Psaradellis said.

Psaradellis and his co-investigators say that operating earlier may make it easier to get an accurate reduction. With other fractures, the longer the injury is left in a displaced, unreduced position, the harder it becomes to reduce it. The investigators applied this thinking to calcaneal fractures.

"The soft tissues tend to contract, so if the calcaneus is shortened to begin with, the soft tissues tend to shorten, and it is difficult to stretch them out in order to reduce the fracture and ultimately close the wound without tension."

In addition to avoiding soft tissue contracture, early ORIF may permit patients to initiate limited range of motion sooner, he said.

This soft tissue protocol is only appropriate for certain patients. Psaradellis and colleagues were fairly aggressive in their study, using the protocol on any closed calcaneal fracture, even very comminuted, high-energy injuries.

"But I think that if people were going to try this protocol, it would be better to try it on less severe injuries at first and develop a comfort level," he said.

He did not recommend using it on open calcaneal fractures because they require different soft tissue management.

For more information:
Psaradellis T, Weber T, Wiersema B, et al. Timing of surgery and wound complications in calcaneus fractures. #21. Presented at the Orthopaedic Trauma Association 22nd Annual Meeting. Oct. 4-7, 2006. Phoenix.
Telly Psaradellis, MD, orthopedic traumatologist, Fox Valley Orthopedic Institute, 2525 Kaneville Rd., Geneva, Ill. 60134; 630-584-1400; psaradellis@yahoo.com.