Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca

Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca

Souborný referát / Current concepts review

ACTA CHIRURGIAE ORTHOPAEDICAE ET TRAUMATOLOGIAE ČECHOSL.,
81, 2014, p. 177 - 196

Zlomeniny patní kosti: současná koncepce léčení

Fractures of the Calcaneus: Current Treatment Strategies

S. RAMMELT, H. ZWIPP
University Center for Orthopaedics and Traumatology, University Hospital Carl-Gustav Cams, Dresden, Germany

SUMMARY

Displaced, intra-articular fractures of the calcaneus represent a surgical challenge and the ideal choice of treatment remains a subject of continued debate. Open reduction and stable internal fixation without joint transfixation has been established as the standard treatment for most of these fractures with good to excellent results in more than two thirds of patients in larger clinical series. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposition of the fractured lateral wall, the subtalar and calcaneocuboid joints, but wound healing problems cannot be completely avoided despite meticulous soft tissue handling. Percuatneous and less invasive procedures have successfully lowered the rates of wound complications but exact anatomic reduction remains an important issue. Care must be taken not to overlook atypical fractures like sustentacular fractures and fracture-dislocations of the calcaneus that are treated with a small medial or curved epimalleolar lateral approach, respectively. The use of bone grafting or bone substitutes for defect filling appears not necessary in most cases. Prognostic factors that can be influenced by the surgeon are anatomical reduction of the overall shape of the calcaneus and congruity of the subtalar joint which should both be controlled intra-operatively. Treatment results are adversely affected by severity of injury, open fractures, bilateral fractures, a high body mass index and smoking. Early, stable soft tissue coverage with pedicled or free flaps appears to lower infection rates and improve the functional results after open fractures. Calcaneal malunions and nonunions are disabling conditions resulting from either non-operative treatment or inadequate reduction and fixation of displaced fractures. Deformity correction is tailored to the type of deformity and individual patient needs. Treatment options include lateral wall decompression, in situ- or corrective subtalar arthrodesis and calcaneal osteotomies accompanied by soft tissue-balancing.

Key words: calcaneus, fracture, subtalar joint, internal fixation, sustentaculum, fracture-dislocation, malunion

INTRODUCTION

Few issues have generated as much controversy in traumatology as the treatment of displaced, intra-articular calcaneal fractures, and they continue to do so today. The reasons for that are manyfold. Calcaneal fractures display a wide range of injury patterns with about 80% being intraarticular and their operative management is challenging with a considerable learning curve for the surgeon (46, 58, 72). The soft tissue cover around the calcaneus is delicate with a vulnerable layer of skin over the lateral calcaneal wall that is prone to wound healing problems and a unique plantar skin that cannot be replaced with adequate tissue once it is avulsed or severely damaged (2, 19). A  substantial proportion of calcaneal fractures result from axial impact inflicting a great number of young male industrial workers thus having a  considerable socio-economic impact (60). Axial impation also results in a  primary cartilage damage that may lead to posttraumatic arthritis irrespective of the kind of treatment. On the other hand, we are witnessing an increasing number of low-velocity injuries in the elderly population with osteoporosis or diabetes that are challenging to treat and prone to complications (29).

From a historical prespective, the treatment concepts for calcaneal fractures have witnessed numerous changes over the last 150 years (52). One of the first to propose internal fixation with a nail was Carl Gussenbauer from Prague in 1888 (27). Over

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