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- Fall from height – common associated injuries include other calcaneum, ankle, tibia, knee, femur, hip, acetabular, pelvis, and lumbar spine injuries
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- 'Constant fragment' – Anteromedial fragment consisting of sustentaculum tali and middle facet. FHL runs underneath
- 3 ligaments attach to sustentaculum tali: tibiocalcaneal ligament, talocalcaneal ligament, and calcaneonavicular (spring) ligament
- Due to the presence of these ligaments, this fragment is “constant” in fractures of the calcaneum
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- 4 articulating facets – anterior, middle (on sustentaculum tali), and posterior facets articulate with talus; fourth facet articulates with cuboid
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- Line 1 = highest point of posterior facet to highest point of tuberosity
- Line 2 = highest point of anterior process to highest point of posterior facet
- Angle is reduced in a calcaneum fractures
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- Line 1 = along posterior facet
- Line 2 = anterior process to inferior portion of posterior facet
- Angle is widened in a calcaneum fractures
- Harris Axial view – assesses varus deformity and lateral wall blow out
- Broden's view – visualizes subtalar joint (useful for intraoperative assessment)
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- Sagittal – extent of collapse
- Coronal – heel widening, varus deformity, lateral wall blow out
- Axial – Sanders classification, size of constant fragment
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- Essex-Lopresti classification – divides into tongue type vs joint depressed (75%)
- Joint depressed = Secondary fracture line exits anterior to the Achilles tendon attachment
- Tongue type = Fracture line extends posterior to the posterior tuberosity
- Sanders Classification based on 30 degrees semi-coronal view (perpendicular to the posterior facet) at the widest point of posterior facet
- Type 1 = undisplaced
- Type 2 = 1 fracture line (2 fragments)
- Type 3 = 2 fracture lines (3 fragments)
- Type 4 = comminuted
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- Jones bandage, do not put back slab (to avoid increased pressures on calcanuem), elevate
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- Patient and Injury factors
- Joint depressed (75%)
- No consensus on optimal treatment. Several studies show no difference in outcomes for operative vs non-operative treatment for comminuted Sanders type 4 (Buckley 2002 et al, Agren et al., UK HEFT Trial). However, my decision will be based on patient and injury factors
- Injury Factors - comminuted, subtalar joint disruption → high risk of secondary OA. These factors favor fixation for 2 reasons:
- Prevents OA
- Even if OA develops, better functional outcomes and fewer wound complications if fusion is needed later (Radnay 2009 JBJS)
- Patient factors - young male, worker, PVD? DM?
- Based on Buckley paper, which found that subgroups benefiting from surgery are women, age < 30 with light workload, no worker's compensation
- Patient factors that may not favor ORIF include the presence of peripheral vascular disease or diabetes.
- As such, will discuss with patient, and have them make an informed decision.
Buckley calcaneus.pdf255.1 KB
UK Heft.pdf194.7 KB
Argen.pdf634.2 KB
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- Restore Bohler angle and calcaneal height
- Restore width for proper shoe fitting
- Correct varus malalignment
- Restore subtalar joint congruity
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- Lateral extensile Approach – Between tibialis anterior and fibula; in line with 5th ray along border of glabrous skin → Full thickness flap (avoid devascularization of lateral calcaneal artery) → Subperiosteal dissection → "Retract with K-wires with meticulous skin handling"
- Sinus Tarsi Approach – Tip of fibula, horizontal to foot for 3-4 cm → EDB retracted superiorly, peroneal tendon retracted inferiorly
- Which approach is better?
- Bai et al. Meta-analysis 2018 - Sinus tarsi approach has lower wound complications (2% vs 20%), with no difference in other outcome scores.
- Beware the SURAL nerve
Bai et al.pdf1.8 MB
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- Schanz pin in calcaneus tuberosity to correct varus deformity
- Use laminar spreader to open the central defect
- Place K-wires and raft screws under posterior facet, securing to the constant fragment
- Fill defect with allograft, autograft, or bone substitutes
- Apply plate
- Consider minimally invasive surgical (MIS) approaches
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- No significant difference in outcomes
- Pitts et al. FAI 2019 found no difference in restoration of angles or complication rates between screws and plates
Pitts et al.pdf433.2 KB
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- Autografts - Iliac Crest Bone Graft (ICBG) - Singh et al. JOT 2013 showed no difference in outcomes or complication rates, though grafts better restored radiographic angles
- Allografts - Duymus et al. JFAS 2016 demonstrated no difference in clinical outcomes, but grafts better restored Bohler angle
- Bone substitutes are also an option
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- Aware of the UK HEFT Trial - RCT of 151 patients which found no difference between operative and non-operative treatment.
- Strict exclusion criteria – excluded Sanders 3 and 4 fractures. This created selection bias as only mild calcaneal fractures were included.Strict exclusion criteria – excluded Sanders 3 and 4 fractures. This created selection bias as only mild calcaneal fractures were included.
- Only 30% of eligible patients were randomizedOnly 30% of eligible patients were randomized
- All used extensile lateral approachAll used extensile lateral approach
- Due to strict exclusion criteria, the study found no difference in outcomes
HEFT.pdf2896.3KB
pearce2015.pdf194.7KB
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- RCT comparing operative vs non-operative treatment using extensile lateral approach in 512 patients. Found no difference in outcome for displaced intra-articular calcaneal fractures.
- Subgroups that benefit (3)– Women, patients under 29 with light workload, and those without worker's compensation
Buckley calcaneus.pdf255.1KB
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- Controversial.
- Buckley 2002 RCT found that 25% of Sanders 4 fractures needed secondary fusion within 2 years anyway. So this suggests that one can consider primary fusion in these fracture subtypes.
- Buckley et al. 2014 JOT RCT. Sanders 4 ORIF (17 patients) vs ORIF + primary subtalar fusion (14 patients) - no difference functionally. Primary fusion may reduce cost and time off work.
- Authors concluded that it remains the choice of surgeon and patient.
buckley2014.pdf365.4KB
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- Radnay 2009 JBJS
- Compared non-operative treatment followed by fusion versus ORIF followed by fusion; better functional outcomes and fewer wound complications in patients who had initial ORIF
radnay2009.pdf491.9KB
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- Wound complications
- Subtalar arthritis
- Subfibular impingement → peroneal irritation
- Malunion
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- "Distraction bone block subtalar arthrodesis" → to address loss of calcaneal height
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The desire of the righteous ends only in good, the expectation of the wicked in wrath. Proverbs 11:23