Severity of injury predicts inferior calcaneal fracture repair

Issue: November/December 2013

Researchers from Germany identified severity of injury, open fractures, bilateral fractures and work-related injuries among the factors that predict less favorable outcomes in patients with intra-articular fractures who undergo anatomic reduction and internal fixation.

“We still have to strive for anatomic reconstruction of articular surfaces and then we can expect reasonable results, but in 75% of patients, not in 100%,” Stefan Rammelt, MD, PhD, of University Hospital Carl Gustav Carus, Technische Universität, in Dresden, Germany, said at a recent meeting.

Rammelt and colleagues studied 210 consecutive patients who underwent anatomic reduction and internal fixation of displaced intra-articular calcaneal fractures between 2000 and 2003.

Investigators performed the surgery with a standardized lateral approach in 80% of patients or a combined approach in 20% of them.

The average time from fracture to surgery was 10 days.

“We started at the posterior facet of the subtalar joint and reconstructed the joint from medially to laterally,” Rammelt said. “We used a dry scope to see if the joint reduction was fine.”

The researchers were able to follow-up 127 patients with 149 fractures at 94.3 months, average, after surgery.

At follow-up, the median Zwipp score was 60, the median AOFAS ankle/hindfoot score was 77, the median Foot Function Index score was 26.7, the median SF-36 mental score was 54.6 and the median SF-36 physical score was 44.5, based on the study results.

Case example of a 45-year-old male patient with a displaced intra-articular calcaneal fracture of his right foot (a). CT scanning revealed the number of main fragments and involvement of the anteromedial facet of the subtalar joint. Open reduction and internal fixation was performed with a lateral interlocking calcaneal plate (b). The patient was followed up at 88 months; the implants had been removed elsewhere at 2 years (c).

Prognostic factors for a negative outcome included severe injuries measured on the Sanders and Zwipp classifications, open fractures, concomitant injuries, older age and work-related injuries.

“The Zwipp classification takes into account the number of main fragments and fracture joint facets as well as the accompanying soft tissue damage,” Rammelt said.

Four patients with Böhler’s angles that measured less than 15° as compared with the uninjured side and 11 patients with a subtalar joint step off of 2 mm or more had inferior outcomes.

“We can give patients right when they come in an estimate of how results will be,” Rammelt said.

Wound edge necrosis occurred in 14.7% of patients and it healed with open wound care; however, surgeons needed to revise the wounds for hematoma in four patients and for deep soft tissue infection in eight patients. Two patients needed free flaps for soft tissue coverage, he said.

At postoperative follow-up, none of the patients had chronic osteomyelitis or nonunions, but 6% of them required secondary subtalar fusion between 2 years to 5 years. – by Renee Blisard Buddle

Reference:
Rammelt S. Paper #75. Presented at: American Orthopaedic Foot and Ankle Society Annual Meeting; July 18-20, 2013; Hollywood, Fla., USA.

For more information:
Stefan Rammelt, MD, PhD, can be reached at Department of Trauma and Reconstructive Surgery, University Hospital Carl Gustav Carus, Technische Universitãt Dresden, Fetscherstr. 74, 01307 Dresden, Germany; email: stefan.rammelt@uniklinikum-dresden.de.

Disclosure: Rammelt receives research support and travel expenses from AO Trauma, is the foot and ankle section editor of the Journal of Orthopaedic Trauma, is on the editorial board of Operative Orthopaedics and Traumatology, Fuss & Sprunggelenk and Biomatter and is a board member of the German Orthopaedic Foot and Ankle Society, German Society for Biomaterials and German Society for Orthopaedics and Traumatology.