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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

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 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”
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
slide24
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
slide25
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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