External fixation comparable to ORIF for intra-articular calcaneal fractures

At final follow-up, over 90% of fractures treated with percutaneous reduction and external fixation showed good or excellent clinical results.

Percutaneous reduction and external fixation appears to be a reliable alternative to internal fixation for stabilizing intra-articular calcaneal fractures and may achieve similar results, according to a study by researchers in Italy.

Bruno Magnan, MD, and colleagues at the University of Verona, reviewed their results using the approach in 54 closed articular displaced fractures in 52 patients treated at a mean age of 48.6 years. Using the Sanders classification system, surgeons classified 15 (28%) fractures as type 2, 31 (57%) fractures as type 3 and eight (15%) as type 4, according to the study.

Patients underwent surgery at an average of 5.4 days postinjury. All procedures were performed under image intensifier control, and surgeons used an appropriately sized Orthofix Mini-Fixator (Orthofix spa) for external fixation. These devices feature a uniplanar joint, perpendicular axis pins and a small slide that supports a clamp, allowing for adjusting frame length, according to the study.

"After the fixator has been applied, further reduction and elevation of the thalmic fragment may be carried out by elogating the clamps on the slide using the appriopriate key in the distraction mechanism," the authors said.

No weight-bearing was permitted for 8 weeks postoperatively, although both passive and active ankle and peritalar joint mobilization were immediately initiated. Surgeons removed the external fixator after 8 weeks for Sanders type 2 fractures and after 10 weeks for types 3 and 4 fractures. Intensive active and passive mobilization was continued for another 2 months after fixator removal, according to the study.

At 49 months' mean follow-up, no patients had required further surgery. Using the Maryland Foot Score, the researchers found that 26 of the 54 cases (48.1%) achieved excellent clinical results, 23 cases (42.6%) had good results, two cases (3.7%) had fair results and three (5.6%) had poor results, according to the study.

"The poor results were observed in noncompliant patients in whom collapse of the calcaneal body was caused by early weight-bearing against medical instruction," the authors said.

At final follow-up, the mean functional score, measured using the Score Analysis of Verona, had significantly improved to 25.66 from 17.58 preoperatively (P<.01). Of the 54 cases, 24 cases (44.4%) had excellent results, 25 (46.3%) had good results, three (5.6%) had fair results and two (3.7%) had poor results, according to the study.

The mean Böhler's angle also significantly improved postoperatively, with 39 cases (72.2%) improving 20°, the authors said.

Ten cases (18.5%) experienced transient local post-traumatic osteoporosis, which resolved within 4 months, and three cases (5.6%) developed superficial pin track infection, according to the study.

For more information:
Magna B, Bortolazzi R, Marangon A, et al. External fixation for displaced intra-articular fractures of the calcaneum. J Bone Joint Surg Br. 2006;88-B:1474-1479.