Percutaneous reduction and external fixation reliable for heel fractures

VIENNA – Percutaneous reduction and external fixation has shown to be a reliable technique to obtain a stable reduction of intra-articular, displaced calcaneal fractures, according to Italian investigators.

“The goals of external fixation are to provide a successful reduction through a minimally invasive treatment,” Elena Manuela Samaila, said at the 10th EFORT Congress, here.

“We found that external fixation was effective in obtaining reduction of talar fragments, Böhler’s angle and coronal and axial realignment,” she said. “Excellent to good results were seen in 80% to 90% of the series.”

Samaila presented the investigation results which assessed 54 fractures in 52 consecutive patients at an average age of 48.6 years who underwent treatment with the Orthofix Heel Mini-Fixator (Orthofix spa, Verona, Italy) for Sander’s type II, III and IV os calcis fractures.

“In this particular kind of fracture, in which outcomes are critical with all surgical or conservative treatments, today MIS (minimally invasive surgery) by percutaneous reduction and external fixation can provide absolutely comparable results to those reported with ‘traditional’ open surgical procedures with the reduction of the risk of complications, surgical, hospitalization and recovery times,” co-author, Bruno Magnan, MD, of the Orthopaedics Department of the University of Verona, told Orthopaedics Today Europe. Magnan is the president of the Italian Foot and Ankle Society.

Follow-up averaged 49 months and patients were clinically assessed using the Maryland Foot Score. Radiographic evaluation was performed with X-rays and CT scans.

Nearly 91% of the patients rated their ankles good or excellent in the Maryland Foot Score. Radiographic assessment found the average Böhler’s angle went from 6.98· preoperatively to 21.94· postoperatively. CT scans showed excellent results in 44.4%, good results in 46.3%, fair results in 5.6% and bad results in 3.7%, according to the study abstract.

“Complications seen in the study population included Sudeck’s atrophy in 10 cases, superficial pin tract infections in three cases and thalamic displacement following early weight-bearing in three cases,” Samaila said. “Two patients who scored ‘poor’ required a further procedure for a subtalar joint fusion.”

Compliance

Although studies which involve larger external fixation devices tend to note patient compliance as an issue, Magnan said the small size of the fixator in this investigation made that less of a problem and patient compliance was not assessed.

“The dimension of this device is very small — about 10 cm x 2.5 cm — and, avoiding any immobilization by plaster cast is well accepted by patients, who are allowed to start joint mobilization early,” he said.

Overall, Magnan reported that the clinical results that were seen in this population were comparable to those obtainable with open reduction and internal fixation (ORIF). However, it has the added advantages of being a minimally invasive procedure; substantially shorter operating times; and reduces the risk of complications related to surgical exposure.

Following Samaila’s presentation, she was questioned by audience members concerning the outcomes she presented, especially radiographs that indicated gaps in the reductions in “successful” outcomes.

“With external fixation, you can’t have a perfect subtalar reduction as you would with an open reduction,” she responded. “At follow-up, which was evaluated with CT scans, we found that it was important to restore the 3-dimensional axial alignment and not a perfect subtalar reduction.”

References:
Magnan B, Samilia EM, Viola G, Bartolozzi P. External fixation for intra-articular displaced calcaneal fractures. Paper F375. Presented at the 10th EFORT Congress. 3-6 June 2009. Vienna.
Magnan B, Bortolazzi R, Magnan A, et al. External fixation for displaced intra-articular fractures of the calcaneum. J Bone Joint Surg (Br). 2006;88(11):1474-1479.