Severe calcaneal fractures
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Severe Calcaneal Fractures. Trauma Rounds The Ottawa Hospital Presented by Drs A Liew and M Prud ’ homme-Foster September 11 th , 2012. Overview: Calcaneal fractures. Most common of tarsal bones: 2% of all Articular surface involved in 70% Type IV: 4-28%

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Severe Calcaneal Fractures

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Severe calcaneal fractures

Severe Calcaneal Fractures

Trauma Rounds

The Ottawa Hospital

Presented by

Drs A Liew and M Prud’homme-Foster

September 11th, 2012


Overview calcaneal fractures

Overview: Calcaneal fractures

  • Most common of tarsal bones: 2% of all

  • Articular surface involved in 70%

  • Type IV: 4-28%

  • Conversion to fusion as high as 73% in type IV


Outcomes and expectations

Outcomes and Expectations

  • Magnuson (1923) :“saw practically no fractures of the os calcis which did not result in from 30 to 70 percent disability of the foot”

  • Sanders (2009): “Anatomic reduction of the calcaneus therefore attempts to recreate congruent subtalar and calcaneocuboid joints, to achieve a reduced lateral wall and peroneal tendons, and to restore calcaneal height, hindfoot alignment, and talar declination. Patients should expect to wear regular shoes, to exhibit a normal gait, and to remain pain-free for an extended period of time”


The ottawa experience

The ‘Ottawa Experience’

  • SurveyMonkey(R) 2012, MPF et al.

  • 3 question survey in plane English: anonymous answers

  • 16 of 22 staff respondents (73%) over a 2-day period


The ottawa experience1

The ‘Ottawa Experience’

Question 1: Considering the last ten years, how many calcaneal fractures Sanders type 3/4 have you been responsible for managing?


The ottawa experience2

The ‘Ottawa Experience’

Question 2: With regards to management, which of the following have you used?


The ottawa experience3

The ‘Ottawa Experience’

Question 3: Would you consider primary subtalar fusion with reconstruction for a severe calcaneus fracture?


The ottawa experience4

The ‘Ottawa Experience’

Question 3: Would you consider primary subtalar fusion with reconstruction for a severe calcaneus fracture?

  • Comments Correlated to Volume

  • But I would refer patient for treatment (1-5)

  • Not personally, as I would refer, but I might consider it if referral not an option (1-5)

  • But rarely - rather reconstruct for height and fuse late (6-10)

  • Never primary arthrodesis they need to have pain as a late outcome (10+)

  • Maybe, but I haven't seen one yet. And, give it a shot, nothing to lose with ORIF. Sometimes you win big and the patients does well (10+)

  • Older patient with good skin and low comorbidity risk and wide heel (+10)


Which ones to fuse

Which ones to fuse?

  • JOT 2003: Review of prospective, randomized trial database, 471 fractures

  • 44 patients required fusion and were compared to others

  • SF-36,VAS, OAS, Sanders and Crosby

  • Primary prognostic determinant: Bohler angle on presentation

    • <0° ten times more likely to require subtalar fusion than >15°

    • Sanders type IV 5.5 times more likely than type II

    • WCB three times more likely than non-WCB


Fusing later

Fusing later…

  • JBJS 2009: 75 DIACF consecutive series for subtalar fusion for post traumatic OA

  • Looked at fusion after nonop v. ORIF

  • Very few Sanders type IV

  • However was able to show that better outcomes for fusion in ORIF group and easier to achieve height and alignment


Be careful of ageism

Be Careful of Ageism

  • JBJS 2010: Retrospective 158 fractures, two groups, cut-off 50yoa

  • 8.98yrs follow-up

  • Differences: ASA, mechanism of injury, Worker’s comp

  • Outcome: Older group scored better on all clinical assessments

  • JBJS 2002: Prospective 471 fractures, stratified groups

  • 2-8 yrs follow-up

  • The best patients to treat nonoperative are those who are fifty or older, males and Workers’ comp


New advances

New Advances?

  • Injury 2010: 37 consecutive Sanders type IV treated with primary fuison

  • AOFAS mean of 75.43 and corresponded to reconstructing Bohler angle

  • Mean increase of Bohler: 5.26° (normal: 25-40°)

  • Suggest ‘high clinical effectiveness’: However…


Primary fusion

Primary fusion?


Primary fusion1

Primary Fusion

  • Foot and Ankle Surgery 2012

  • Aim: assess the functional outcome of the primary arthrodesis in the management of comminuted displaced intra-articular calcaneal fractures


Primary fusion2

Primary Fusion

  • Lit. search from 1990-2010, eight publications , 128 calcaneus

  • Follow-up 28 months (12-59)

  • Time between injury-arthrodesis: 6-22 days


Primary fusion3

Primary Fusion

  • Union: 124 of 128

  • AOFAS: 77.4 (72.8-88) out of 94 max

  • 75% good-excellent

  • Return to work: 75-100%

  • Wound healing or infection: 21 of 108 (19.4%)

    • 7 amputations


Primary fusion4

Primary Fusion

  • Coleman Methodology: 56 (small and flawed)


Primary fusion5

Primary Fusion

  • Only two studies comparing fusion vs fusion after ORIF: slight advantage to primary

  • One study looking at minimally invasive (Vira)

  • Current rate of primary fusion: 0.4-15% (5%)

  • Conclusion:“the process of choosing the best treatment modality for a severely comminuted calcaneal fracture, the primary arthrodesis should receive full consideration”


Evidence on the way

Evidence on the way…


A blast from the past

A blast from the past


Summary

Summary

  • Sanders type IV extremely difficult to manage

    • 9% good and 91% fair/poor

    • Much more likely to require fusion

  • Both nonop and ORIF lead to poor results but fusion better after reconstruction

  • Better outcomes more often with early fusion

  • Choose patients based on Bohler angle and risk factors


Severe calcaneal fractures

  • Background

  • Outcomes

    • ORIF

    • Non op

    • Fusion

      • Primary vs delayed

        • p.808: Thermann et al.28 assessed 17 patients with secondary arthrodesis, and obtained a mean of 69 points on the AOFAS scale, while in cases of primary arthrodesis, they found a mean of 88 points. These extraordinary results have not been established elsewhere. -- Highlighted 2012-09-09

      • After ORIF or after non-op

        • 1.Radnay CS, Clare MP, Sanders RW. Subtalar Fusion After Displaced Intra-Articular Calcaneal Fractures: Does Initial Operative Treatment Matter?Surgical Technique. J Bone Joint Surg Am. The Journal of Bone and Joint Surgery; 2010 Feb. 28;92(Supplement_1_Part_1):32–43.

      • Vs ORIF

    • Minimally invasive


Severe calcaneal fractures

  • What are the results of non-op?

  • What are the results of ORIF?

    • Pain and function

    • Complications

  • What percentage go on to be fused?

  • Is fusion late as good as primary fusion?

  • Which ones will require fusion?

    • 1.Csizy M, Buckley R, Tough S, Leighton R, Smith J, McCormack R, et al. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma. 2003 Feb.;17(2):106–12.

    • Showed us that the degree of initial injury (Bohler angle < 0°) was the primary prognostic determinant on long term outcomes

    • Nonop was 5 times more likely to require fusion

  • Does fusion type matter?

    • 1.Csizy M, Buckley R, Tough S, Leighton R, Smith J, McCormack R, et al. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma. 2003 Feb.;17(2):106–12.


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