International Journal of Orthopaedics Sciences 2016; 2(4): 381-384

ISSN: 2395-1958
IJOS 2016; 2(4): 381-384
© 2016 IJOS Our Experience with Operative Treatment of intra-
www.orthopaper.com
Received: 01-09-2016 articular calcaneal fractures with calcaneal plates
Accepted: 04-10-2016

Dr. Channabasava Patil Dr. Channabasava Patil and Dr. Chandrakanth PN Shetty
Associate Professor, Department
Of Orthopedics, Oxford Medical
College, Hospital and Research DOI: http://dx.doi.org/10.22271/ortho.2016.v2.i4f.60
Center, Bangalore, Karnataka,
India Abstract
Background: Surgical treatment using open reduction and stable osteosynthesis of displaced calcaneal
Dr. Chandrakanth PN Shetty fractures has become a standard method of treatment in recent times. The purpose of this study was to
Assistant Professor, Department determine whether open reduction and internal fixation of displaced intra-articular fractures results in
Of Orthopedics, Oxford Medical better general and disease specific outcomes at 1 year after injury.
College, Hospital and Research Materials and Methods: Between Febraury 2012 and December 2015, 28 Patients with intra-articular
Center, Bangalore, Karnataka, calcaneal fractures were treated with calcaneal plates (locking and non-locking) using standard extended
India lateral approach to calcaneum. Patients were evaluated by history, physical examination and radiography.
Fractures were assessed by preoperative CT Scans in selected complex fracture patterns. Bone grafts
were not added when a locking plate was used. Treatment results were evaluated by AOFAS Ankle-
Hindfoot Scale at different follow-up periods ranging from 6months to 3years.
Results: Wound healing complications were noted in 4 patients (~14%), which was the most frequent
complication. Implants were removed in a total of 4 patients, in one case because of severe swelling,
where the patient had early implant removal after 3months of surgery. All fractures united eventually and
no patient had deep osseous infection or foot compartment syndrome. Overall results according to the
AOFAS Ankle-Hindfoot Scale were Good to Excellent in 23(~83%) Cases.
Conclusion: Open reduction and internal plate fixation of intra-articular fractures is associated with low
complication rates and gives better quality of life after the surgery. The method has been improved by
implanting locking compression plates, osteosynthesis is more stable, enables early weight bearing, and
bone-grafing is rarely necessary. Outcome scores in this study tend to support ORIF for calcaneal
fractures when there is a clear indication.

Keywords: intra-articular calcaneal fracture, calcaneal plate, AOFAS Ankle-Hindfoot Scale

Introduction
Calcaneal fractres are relatively rare injuries, with reported occurence of 2% of all fractures.
The intr-articular types constitute to 75% of calcaneal fractures and historically have been
associated with poor functional outcome.
These fractures mostly occur due to an axial load such as a fall from a height or a motor
vehicle accident or sometimes by fall of a heavy object over the heel. These fractures occur as
an axial load force is applied to the posterior facet of the calcaneus through the talus, shear
forces are directed through the posterior facet toward the medial wall of the calcaneus. These
injuries may be associated with other axial load injuries such as lumbar spinal, pelvic and
tibial plateau injuries and these injuries are more common in higher-energy injuries.
Approximatey 10% of injuries are bilateral and less than 5% are open injuries. Many calcaneal
fractures are work related, as they result from a fall from height, especially in males age 35-45
years. These fractures frequently result in long-term disability with potentially severe
economic impact on the patients and their family.
Historically, treatment of displaced intra-articular fractures has varied from non-operative
Correspondence management with or without closed reduction, to open reduction with internal fixation by
Dr. Channabasava Patil various surgical approaches, to primary arthrodesis. The non-surgical treatment was popular
Associate Professor, Department might be related to the potential for wound complications in many and possibly osteomyelitis
Of Orthopedics, Oxford Medical
College, Hospital and Research
in some of the surgically treated patients. However, over the past two decades the interest has
Center, Bangalore, Karnataka, swung back towards surgical management due to improved surgical techniques and less soft
India tissue stripping.
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Although many pioneers in the field introduced screw or plate edema decreased and there were positive wrinkles on hind foot
fixation of the broken calcaneus, surgical treatment using open soft tissues. The surgery was performed under tourniquet, with
anatomical reduction and stable internal osteosynthesis is only the patient placed in lateral decubitus position, under
commenced at the start of the 1980s. The treatment was made intraoperative fluoroscopy control (Broden's views). The
possible by the introduction of new imaging methods such as standard extended lateral approach with L-shaped incision
CT which allowed better detection of the fracture pathology (Seattle Type) were used. Posterior and calcaneal facet
and provided the basis for new surgical strategies. The Foot reconstruction including the Gissane's angle, Böhler's angle
and Ankle Expert group of the AO Foundation together with with calcaneal height, width, length restoration, and no varus–
Synthes USA developed an anatomically an shaped valgus deviation were main goals of open reduction. Calcaneal
interlocking calcaneal plate, which has been available since plates (both locking and non-locking) were used to stabilise
2002. the fractures. Bone Grafting was not performed in any Cases.
Plate osteosynthesis of the intra-articular fractures is a
standard treatment method, but it has potential complications
such as poor wound healing and infection. The complications
of wound healing may occur because of not enough precisely
performed incisions. Calcaneal shape restoration by means of
open reduction internal fixation (ORIF) or primary subtalar
arthrodesis if needed helps in prevention of late complications
such as malposition, flattening of the longitudinal arch,
anterior ankle impingement syndrome, lateral impingement
syndrome, and axial malalignment of the hind foot. The
locking compression plate (LCP) has improved the functional
results, limited the indications for bone grafting, and shortened
the treatment.
The purpose of this study was to determine whether open
reduction and internal fixation of displaced intra-articular
fractures using calcaneal plates results in better general and
disease specific outcomes at 1 year after injury.

Materials and Methods

28 intra-articular calcanal fractures in 28 patients were treated
by means of open reduction and internal plate fixation from
February 2012 to December 2015.
The most frequent mechanism of injury was fall from a height.
Other mechanisms of injuries were motor vehicle accidents or
fall of a heavy object on the heel. There were 23 males and 5
females patients in our study with an average age of 41 years
(range 14 -63 years). One patient had an open fracture (Type 2,
Gustilo and Anderson Classification) with the wound over the
medial side of calcaneal area.
Fig 1: Intra Operative Photograph (above) showing the
Table 1: Characteristics of Studied groups (Calcaneal fracture study, extended lateral approach used, and opening of Lateral
28 fractures in 28 patients) calcaneal wall is gently pried laterlly to expose intra articular
Age Group No. of Patients
fragments and a model of locking calcaneal plate used (below)
<25 Years 01 After the surgery, A sterile compressive elastic dressing was
25-35 years 06 given. Range of motion exercises began immediately on the
35-45 years 13 first postoperative day. The progressive weight-bearing was
> 45 years 08 started after 8 weeks, initially with 30% of their weight.
Patients were allowed full weight-bearing after 12 weeks,
Patients were evaluated by a detailed history, physical provided that reduced and stabilized fracture position stayed
examination and radiography. X rays taken included axial unchanged and signs of bone healing were present. When LCP
calcaneal views along with routine antero-posterior and lateral had been applied, we started up progressive weight-bearing
views. Other associated inuries were looked for and noted. two weeks earlier, because of better stability of locked screws
Computed Tomography with Sanders CT Scan Classification in plate. Hardware removal was considered unnecessary unless
was used in selected patients with complex fracture patterns. there were complications. Post Operative X-ray imaging
Displaced calcaneal fractures (posterior articular facet step off including Axial calcaneal views, were obtained on the 4th, 8th,
more than 2mm, significant shortening, loss of height, and and 12th week, and then 6th, 12th, and 24th month after the
widening of the calcaneus, i.e., Böhler's and Gissane's angle surgery.
variations) were included in the operative treatment. In all The Patients were followed up for a minimum 12 months after
these cases, we performed primary osteosynthesis with surgery (maximum follow up 3 years). The Radiographs and in
restoration of the calcaneal shortening, loss of height, selected cases CT Scans were analysed one year after the
broadening and intra-articular joint restoration of subtalar operations. The late complications and funtional outcomes
joint. including patients' satisfaction were evaluated at regular
We operated usually from the 3 to 10 days after injury (earlier outpatient examinations. On the radiographs and CT scans,
if the soft tissue conditions are good), when the soft tissue Böhler's, Gissane's, talocalcaneal angle (TCA), talus first
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metatarsal angle (TFMA), and calcaneal inclination angle Overal Treatment results were evaluated by AOFAS Ankle-
(CIA) were measured and evaluated. Hindfoot Scale at different follow-up periods ranging from
6months to 3years.

Results
Twenty four of all 28 wounds (~86%) healed with primary
intention. Superficial healing defects (wound edge necrosis,
skin edema blisters, superficial wound infections) occured in 4
(~14%) cases. Most of the wounds eventually healed with no
patient having deep osseous infection. In one patient the plate
had to be removed for subsequent successful healing process.
Implants were removed in a total of 4 patients, in one case
because of severe swelling, where the patient had early
implant removal after 3months of surgery. Time of hardware
removal varied from 3 months to 2 years after the surgery.

Fig 3: Post Op Heel Rise with Ankle Plantar flexion in a Patient, One
year after injury.

The AOFAS Ankle-Hindfoot Scale

we achieved excellent to good results in 23(~83%) cases

Table 2: Overall Results According to A OFAS Ankle-Hindfoot

Scale
No. of Patients (%)
Excellent 06 (~21%)
Good 18 (65%)
Fair 03 (~10%)
Poor 01 (~4%)

Conclusion
Open reduction and internal plate fixation of intra-articular
fractures is associated with low complication rates and gives
better quality of life after the surgery. The method has been
improved by implanting locking compression plates,
osteosynthesis is more stable, enables early weight bearing,
and bone-grafing is rarely necessary. Outcome scores in this
study tend to support ORIF for calcaneal fractures when there
is a clear indication.
In the Last Decade, Open reduction and internal plate fixation
of displaced intra-articular fractures has become a standard
surgical method with low complication rate and better quality
of life after the surgery.
Rates of wound complications that achieved~14% in our study
is comparable with the results published in literature of the last
Fig 2: Preoperative, Postoperative and follow-up (at 3 months) Xrays decade. Many of the wound complications may be avoided by
of a patient showing intra-articular fracture of calcaneum, treated with proper planned incisions and taking extreme care of soft
ORIF using a locking calcaneal plate and showing signs of bony tissues during exposure and closing the flaps. We may finally
union at follow up.
conclude that, properly timed open reduction and internal
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fixation with calcaneal plates in indicated cases, taking care of

soft tissue envelope and early controlled rehabilitation leads to
therapeutic success in displaced calcaneal fractures.

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