OTA 2006 Posters

Scientific Poster #44 Foot and Ankle

Percutaneous Treatment of Displaced Intra-Articular Calcaneus Fractures
Bret T. Kean, MD (n); Scott M. Ciaccia, BS (n); Heather A.Vallier, MD (n);
MetroHealth Medical Center, Cleveland, Ohio, USA

Purpose: The optimal treatment for displaced intra-articular calcaneus fractures remains controversial. Soft-tissue injury and medical risk factors may increase the frequency of complications after surgical treatment through an extensile approach. Preliminary reports suggest percutaneous treatment as an alternative method of improving and maintaining fracture alignment. The purpose of this study was to compare the early results of percutaneous reduction and fixation of calcaneus fractures with traditional open reduction and internal fixation (ORIF).

Methods: We performed a retrospective, IRB-approved review of medical records and radiographs of displaced calcaneus fractures treated operatively by one trauma fellowship-trained surgeon over a 48-month period. All patients underwent ORIF (n = 29 patients, 32 fractures) or percutaneous reduction and small fragment screw fixation (PF) (n = 17 patients, 18 fractures) at the discretion of the surgeon. The mean ages of these patients were 44.8 years (range, 24 to 58) and 46.1 (range, 25 to 72), respectively. Relative indications for percutaneous treatment included amenable fracture pattern, severe soft-tissue injury, and/or medical risk factors. Fractures were classified using the OTA classification: 73A, n = 1; 73B, n = 3; 73C, n = 28 in the ORIF group; and 73B, n = 1; 73C, n = 17 in the PF group. Four fractures in each group were open, and underwent urgent debridement and irrigation, with definitive fixation in a second surgical setting. One patient in the PF group developed compartmental syndrome and had fasciotomy prior to definitive fixation. Ipsilateral foot and ankle injuries were seen in 2 patients with ORIF and 6 patients with PF. Other contralateral foot and ankle injuries were seen in 6 patients with ORIF and 3 patients with PF. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were administered after a minimum of 12 months of follow-up.

Results: Mean follow-up was 27 months, (range, 6 to 40 months). All fractures united primarily without loss of alignment, except for one patient who experienced partial loss of reduction after ORIF due to noncompliance. There were no surgical wound complications and no wound infections in either group. One PF patient first presented to our hospital 3 weeks after injury with heel necrosis over the tuberosity fragment, requiring soft-tissue coverage at the time of fixation. He subsequently developed osteomyelitis. Two patients in the PF group elected hardware removal for comfort, and one of these also had an Achilles tendon lengthening. Another patient in the PF group is anticipating reconstructive foot surgery for his longstanding foot deformities due to cerebral palsy. To our knowledge no patients have undergone subtalar arthrodesis or other secondary procedures. Secondary procedures were more common in the PF group (P <0.02). 12 PF and 17 ORIF patients completed outcomes questionnaires. Their FFI scores were 0.41 and 0.28, respectively (P = 0.12). Patients with open fractures had worse FFI scores (0.50 vs closed fractures, 0.27, P = 0.01). Two of 18 PF patients and 2 of 19 ORIF patients were unable to return to employment after their injuries.

Conclusions/Significance: Percutaneous reduction and fixation provides an alternative to ORIF in selected displaced calcaneus fractures. Early results, complication rates, and functional outcomes appear similar to patients who had ORIF. However, more secondary procedures were performed in the PF group. The percutaneous technique is demanding and may be limited to certain fracture patterns. Further study to define relative indications and limitations of the percutaneous technique, and to evaluate long-term follow-up of these patients will be helpful in formulating future treatment recommendations. Regardless of the treatment method, open calcaneus fractures were associated with poor functional outcome scores.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
· The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an "off label" use). · · FDA information not available at time of printing.