functional outcome of surgically treated sanders types ii...

IJSS Journal of Surgery | March-April 2015 | Volume 1 | Issue 2 1

Original Article

Functional Outcome of Surgically Treated Sanders Types II, III, IV Calcaneal Fractures: An Observational Study

Johny Joshi1, Anshul Gupta2, Hari Menon2, Manish Patel3, Dhairya Lakhani4

1Resident, Department of Orthopaedics, New Civil Hospital, Government Medical College, Surat, Gujarat, India, 2Associate Professor, Department of Orthopaedics, New Civil Hospital, Government Medical College, Surat, Gujarat, India, 3Assistant Professor, Department of Orthopaedics, New Civil Hospital, Government Medical College, Surat, Gujarat, India, 4Intern, Department of Orthopaedics, New Civil Hospital, Government Medical College, Surat, Gujarat, India

Abstract

Background: Management of calcaneal fractures has always been in controversy. Many treatment techniques have been described, but specific indications are vague. In this prospective study, we studied the functional outcome of surgically treated intra-articular calcaneal fracture.

Aim and Objective: To study the outcomes in terms of mechanism of injury, intra-operative difficulties, post-operative complication, infection, the range of motion in the surgically managed calcaneal fracture.

Materials and Methods: A total of 32 Patients with 34 calcaneal fractures operated in NCH Surat from September 2012 to December 2014 were included in the study. Pre-op computed tomography (CT) scan carried out in all patients. Maryland foot score was used to evaluate to assess the functional outcome.

Results: Incidence is much more common in males (90.6%), most of the patients being in their 3rd decade of life. The spinal fracture was the most common associated injury (30%). Results according to Maryland foot score were excellent in 26.4%, good in 61.64%, and none of the patients had poor results. Complications include synovitis, broadening and superficial infection. Pre-op CT scan is very useful tool in calcaneal fractures.

Conclusion: Open reduction internal fixation is the ideal treatment for Sanders type 2/3/4. Even Sanders Type IV (which was thought to be associated with poor results) had a good outcome in short-term follow-up. Use of proper surgical timing/technique/asepsis can lead to good or excellent results in more than 90% of patients and avoiding the majority of the complications. Use of beta-tricalcium phosphate is not a cost effective measure as results are similar in all patients. Earlier mobilization, early return to work, good cosmesis, better subtalar motion are all advantages of surgery.

Keywords: Calcium phosphate, Facet, Fracture

INTRODUCTION

The calcaneus is the largest and the most commonly fractured (2%) tarsal bone.1 Fractures of the calcaneus

continue to pose a therapeutic challenge out of proportion to their incidence.

Calcaneus fracture treatment has always been a source of controversy and headache to orthopedic surgeons for at least last century. Irregular bony anatomy, complicated joint mechanics, fragile soft-tissue cover have made these fractures a challenge. Many classification schemes, operative techniques, and post-operative regimens have been proposed, but a gold standard consensus has not been documented. Despite significant advances, definitive management has been slow to progress secondary to the lack of standardization in fracture classification and evaluation.2-4 Experienced surgeons do acknowledge a significant learning curve,5 yet conservative management often times is wrought with functional impairment and disability.6

DOI: 10.17354/SUR/2015/09

Corresponding Author: Johny Joshi, Resident, Department of Orthopaedics, New Civil Hospital, Government Medical College, Surat, Gujarat, India. Phone: +91-8460136229. E-mail: [email protected]

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Month of Submission : 01-2015 Month of Peer Review : 02-2015 Month of Acceptance : 03-2015 Month of Publishing : 04-2015

Joshi, et al.: Management of Intra Articular Calcaneal Fracture

IJSS Journal of Surgery | March-April 2015 | Volume 1 | Issue 22

In 1916, Cotton and Henderson stated, “ordinarily speaking, the man who breaks his heel bone is “done” so far as his industrial future is concerned.”7 This impact propelled the orthopedic community to seek methods to obtain better outcomes. Better outcomes with surgery have been documented with the advent of CT scanning arbeitsgemeinschaft fur Osteosynthesefragen principles of internal fixation, and antibiotics. Open reduction and internal fixation (ORIF) is the preferred method of management for displaced intra articular fractures of the calcaneus.4,8,9 Although technique continue to improve, yet the treatment is challenging and complications are frequent.

The incidence of this injury is low, plus no definite consensus has been made regarding the ideal management. Balance keeps swinging from conservative to surgical to mini open. So it is the need of the hour, to identify treatment techniques, which use lesser hardware, and provide better functional outcomes in terms of shorter duration of treatment, better stability, early weight bearing, pain free joint and minimize incidence of secondary osteoarthritis.

The primary objective of this study was to evaluate the results of surgical managed displaced intra-articular calcaneal fractures in adults in terms of return of range of motion of ankle and subtalar joints, patient satisfaction, intra and post-operative complications, merits and de-merits of bone grafting and to study the epidemiology in the study group.

MATERIALS AND METHODS

The Study SettingThis was a prospective observational study, which was carried out over a period of 27 months (September 01, 2012 to December 01, 2014) in the Department of Orthopedics of New Civil Hospital, Surat, a multispecialty hospital, catering to the population of South Gujarat.

All the subjects, admitted to the New Civil Hospital from September 01, 2012 to April 01, 2014, with fracture calcaneus and were willing to operate, were enrolled for the study.

Before their enrolment, all the participants were explained the nature and the purpose of the study. Consents were obtained from the subjects. The Human Ethics Research Committee of the Government Medical College, Surat approved the documentation of this prospective study, which was submitted under the title, “results of operative management in Intra-articular calcaneal fractures in adults,” on August 22, 2012.

The Study SubjectsAll the patients above 18 years of age, with fracture calcaneus (Sanders Types II, III, IV), mobile before the

injury and willing to operate and participate in the study were included.

While, patients with skeletal immaturity, not willing to give consent for surgery and/or participation in the study, with pathological fractures, past history of trauma over foot, patient unfit for surgery, immobilized patients prior to trauma and vitaly unstable polytrauma patient were excluded from the study.

The Study DesignA total of 46 patients with fracture calcaneus were admitted in the Orthopedics Department of New Civil Hospital, Surat; during that period of 2 years, out of which 32 patients with 34 fractured calcaneus.

During the study period, 32 patients with 34 calcaneal fractures (two of them had bilateral foot involvement) who fulfilled the inclusion criteria were enrolled in this study. A total of 5 patients did not give consent for surgery, 1 was unfit for surgery, 1 was polytrauma patient admitted in surgical intensive care unit and 7 patients were lost in follow-up and hence they were excluded from the study.

The demographic profile, complete histories, information on the vitals, neurovascular examination along with other relevant local and systemic examinations of all the patients who were willing to participate in the study were recorded in a proforma and the patients were subjected to the following radiological investigations - X-ray foot (anteroposterior, lateral and axial), spine (anteroposterior and lateral), pelvis (anteroposterior), computed tomography scan (CT scan) of foot; other relevant investigations were performed wherever required. Tetanus toxoid, broad spectrum antibiotics, anti-inflammatory drugs and analgesics, were administered as indicated.

Sanders classification system was used to classify the fracture patterns and compare the outcome: Two lines A and B divides the Tallus in 3 equal parts, and line C passes just lateral to the sustentaculum tali. Thus these three lines divides calcaneum in four parts and are classified depending upon the location of these lines (A/B/C) and fracture fragments (2/3/4): Type I: All undisplaced fractures regardless of no. of fragments; Type II: Two part fractures of the posterior facet, further classified as II A/II B/II C; Type III: Three part usually with a depressed central fragment. Subtypes include III AB/III AC/III BC based on the location of fracture lines and Type IV: Highly comminuted often has more than 4 fragments.

The temporary splint was provided using below knee slab and the affected part was elevated. The patient was planned for surgery once the edema subsides, and wrinkle sign develops. After surgery, limb elevation was maintained using Bohler splint and injectable antibiotics (injection cefotaxime 1 g intravenous (IV) BD, injection amikacin 500 mg IV BD)



for 2 days, sterile dressing was done using spirit and betadine ointment on second and seventh post-operative days, drain was removed after 48 h of surgery. Ankle was mobilized on the second post-operative day, whenever fixation was sturdy. Sutures were removed on 14th post-operative day. Gradual weight bearing was started from 8 to 12 weeks.

Procedure of SurgerySurgery were performed under spinal or general anesthesia, with either of the following techniques, ORIF with reconstruction of the articular surface of the posterior facet using pneumatic tourniquet control and closed reduction with internal fixation (CRIF) with Steinmann pin incorporated cast or 6.5 cc screw [33]. CRIF was performed in tongue type pattern of fracture (n = 8 calcaneus) while ORIF in joint depression Type (n = 26 calcaneus).

CRIF TechniqueIn this study, 8 calcaneus were operated with this technique. Prone position, sterile preparation (Figure 1), a small stab

incision was placed over the displaced tuberosity of the calcaneum just lateral to the attachment of the tendoachilles. A steinmann pin was introduced into the tongue fragment in a longitudinal direction angling slightly to the lateral side (Figure 2). Under image intensifier control, the fracture was manipulated to elevate the tongue fragment from its depressed position from the body of the calcaneum. The widening of the calcaneum was reduced by applying side to side pressure with the clasped hands and the pin was advanced across the fracture into the anterior fragment of the calcaneum. Either 6 mm cannulated cancellous screws were used, or we retained the ST pin (Figures 3 and 4).

After completion of the technique, the foot was carefully padded and below knee plaster cast applied incorporating protruding portion of the pin. The pin was removed at 4-6 weeks and below knee plaster cast given. After radiological and clinical signs of union, plaster was removed, and mobilization and gradual weight bearing started.

Figure 1: Patient position with C-arm

Figure 2: Intra-operative X-ray showing placement of steinman pin

Figure 3: Intra-operative Image showing placement of guide pin in sustentaculum tali

Figure 4: Intra-operative Image showing fracture reduction with placement of 6.5 cancellous cannulated screw



ORIF TechniqueIn the present study, 26 calcaneus were operated with this technique. All of the patients were operated in lateral position under tourniquet using lateral approach using

instruments as mentioned in (Figure 5), after taking all aseptic precaution tourniquet was inflated after esmark bandage (Figure 6). After that an extensile right angled

Figure 5: Instruments used during surgery

Figure 6: Esmark bandaging applied

Figure7: Incision site incision marking

Figure 8: Elevation of flap, temporary held with k-wires

Figure 9: Reduction of articular facet and void filled with block of beta-tricalcium phosphate

Figure 10: Final placement of plate



lateral incision was kept (Figure 7). Taking the flap down to the periosteum, full thickness flap was elevated and temporarily held with k wires (Figure 8). Lateral wall of the calcaneum was exposed up to subtalar and calcaneocuboid joint. The rectangular chip of lateral cortical bone elevated after drilling multiple holes and medial joint was explored and reduced under the vision and held temporarily with k wires and posterior facet reconstructed as much as possible. The void filled with beta-tricalcium phosphate (B-TCP) blocks/granules as and when required (Figure 9). Tuberosity fixed to the sustentacular fragment with 4 mm cc/Herbert screws. After reducing lateral wall, fixation was performed using locking plate and screws, followed by

closure of the wound after achieving hemostasis (Figures 10 and 11).

Follow-upAll the patients were called for monthly follow-up on outdoor basis and examined and evaluated according to Maryland foot score.3,5

Statistical analysisStatistical analysis was carried out using mean, standard deviation, percentage, and Student’s t-test.

OBSERVATION AND RESULTS

Table 1 suggests that males were more commonly affected; fall from height is the most common mechanism of injury. Joint depression Type is 3 times more common than the tongue type pattern. A spinal fracture is the most common associated injury followed by pelvic injury. The mean duration between injury and surgery is 6.5 days, and it took about 10 weeks for the complete union to occur.

Table 2 suggests that late post-operative complications include broadening of the heel, infection, and impingement. There was a restriction of subtalar motion and ankle motion was by and largely preserved.

DISCUSSION

In the present series, we have studied 32 patients operated in NCH Surat between September 2012 and December 2014, 9 patients were lost in follow-up before 6 months, hence excluded. 34 calcaneal fracture in 32 patients were included in the study. Though the present series is relatively small, and period of follow-up is short, we have compared our observations with that of available literature whenever possible.

Age of the patients in the present study ranged from 21 to 60 years. The maximum number of patients were from 3rd/4th decade, probably this is the age group which is engaged with working in farms and factories.

In the present series, there were 29 (90.6%) males and 3 (9.37%) female patients. In the series reported by

Figure 11: Closure of wound

Table 1: Characteristics of study participants (n=32)Characteristics Male (%) Female (%) Over all (%)Age (mean±SD) 34.8±10.22 34.7±11 34.7±10.11Sex 29 (90.63) 3 (9.37) 32 (100)Mode of injury

Fall from height 28 3 31RTA 1 0 1

Side involvedUnilateral right 14 1 15Unilateral left 13 2 15Bilateral 2 0 2

Associated injuriesSpine 9 1 10Pelvis 2 1 3Contralateral limb 3 1 4Upper limb 0 1 1

Classification of fractureJoint depression 24 2 26Tongue type 7 1 8Sanders Type II 8 1 9Sanders Type III 12 1 13Sanders Type IV 11 1 12

Interval between injury and surgery (days)

6.56±4.18

Follow‑up (months) 11.29±4.1Time to union (in weeks) 9.94±0.95

RTA: Road traffic accident, SD: Standard deviation

Table 2: Post‑operative follow‑up of study participantsComplications Number of patients (%)Broadening of heel 8Synovitis 3Infection 3Impingement 2Varus 2Range of motion

Ankle (°) 58.35°±4.1°Subtalar 22.50°±6.9°



Farrell,12 90% males were involved. In both the series, male outnumber female. Our observation is consistent with the literature. More number of male patients can be explained as more number of males are working in industries.

The fracture occurs more commonly unilaterally. In the present series, 30 were having unilateral fractures, whereas, 2 were having b/l fractures. In the series reported by Farrell12 more than 80% had unilateral fractures.

All patients had fall from height as their mode of injury. One patient had h/o fall in well. To produce a major fracture of calcaneum, extreme trauma is required, and hence they are not infrequently associated with fractures of other parts of the body. 10 (30%) patients had spine injury, 3 (9%) patients had pelvic fractures and 5 (15%) had other injuries. This shows the importance of examining patients in detail to detect associated injuries at time of admission.

In our study, we have followed Sanders classification which is CT based. The CT also helps in formulating a surgical plan. In one patient, we had to change the surgical plan formulated on plain radiograph after we reviewed the CT scan.

Meantime duration between injury and surgery in our series is 6.5 days. We waited for the wrinkle sign before taking the patient to surgery. This is recommended in the literature and hence we could prevent wound complication. The approach used was lateral in all patients where ORIF was performed.

Physiotherapy is also very important for the rehabilitation of the patients all the patients went through a course of active physiotherapy, inversion - eversion exercise from 2nd postoperative day in patients OR + IF.

The patients were allowed gradual weight bearing after 10-12 weeks, after clinicoradiological signs of union. All patients started full weight bearing after 3-4 months of injury. In the present series, the results were evaluated according to the criteria of the “Maryland foot score.” (Internal consistency [Cronbach’s alpha, reliability] for the ministeriums für staatssicherheit [MFS] is 0.82).13

Restoration and maintenance of articular alignment and avoidance of premature weight bearing, early ankle mobilization are a basic requirement of achieving good results. On subjective evaluation all patients were satisfied with operative treatment. One patient had intraoperative ST PIN breakage, which was removed from the heel.

Even sander Type 4 had good results, the patient were satisfied and were able to carry out their daily and office activities within 4-5 months. This suggests Short term follow-up of sander Type 4 are also good. None of our patients underwent primary subtalar arthrodesis.

Tongue type treated with essex Lopresti, ST pin and cast had somewhat less MFS and had broadening and pain as their main complication. This observation might be due to use of less screws and gradual collapse, but because of less number of patients (only 8) generalized comment cannot be made on this topic.

In our study, because of inadequate reduction, one patient underwent revision from CR+IF with ST pin to OR+IF with locking plate, and the proper reduction was obtained.

Three patients had superficial infection, taking proper aseptic precaution and proper incision; elevating full thickness flap can reduce post-operative infection. 8 patients had broadening of the heel but did not interfere with shoe wear or daily activities. Two patients had varus heel, but they also did not complain of any hindrance in daily activity. Two patients complained of impingement.

B-TCP was used in 9 patients and functional outcome in patients with (85.22)/without (83.2) (by Student’s t-test) BTCP was almost similar. (Consistent with the study of Singh and Vinay: Functional outcome and complication were similar bone graft and no graft groups).14 Similar results in patients with/without the use of bone analog. This might prove that use of artificial bone analog in calcaneal fracture would not be cost-effective, as β-TCP is much costlier. However, freely available autologous iliac crest cancellous graft can be used whenever required.

Table 3: Functional outcome of subject in terms of Maryland foot scoreFunctional outcome Overall number (%) Sander’s Type II (%) Sander’s Type III (%) Sander’s Type IV (%)Maryland foot score (mean±SD) 83.68±6.8 82.56±8.99 85.77±5.95 82.25±5.97Excellent (90‑100) 9 3 5 1Good (75‑89) 21 4 7 10Fair (50‑74) 4 2 1 1Poor (<50) 0 0 0 0Over all 34 (100) 9 (100) 13 (100) 12 (100)B‑TCP Total number MFS P valueUsed 9 85.22±6.85Not used 25 83.25±7.08

B‑TCP: Beta‑tricalcium phosphate, MFS: Ministeriums für staatssicherheit, SD: Standard deviation



Based on the outcomes of our study, we would agree with the literature reviewed and recommend surgical management for Type II/III Sanders and possibly for Type IV. The surgical approach recommended would be lateral with care to erase full thickness flaps. Yet, as the sample size is small and duration of study short further studies are recommended. Good initial and post-op bohlers angle corresponded with the better functional outcome (Tables 3-5).

CONCLUSION

ORIF with restoring the articular congruity with low profile locking plate is the ideal treatment for joint depression type and Sanders Type II/III and IV. Even Sanders Type IV (which was thought to be associated with poor results) had a good outcome in short-term follow-up.

Use of proper surgical timing/technique/asepsis can lead to good or excellent results in more than 90% of patients and avoiding the majority of the complications. Thus ORIF in these patients should be encouraged.

Use of β-TCP is good in restoring calcaneal height intra-op, but is not a cost effective practice because of high cost and similar outcome in all patients. Earlier mobilization, early return to work, good cosmesis, better subtalar motion are all advantages of surgery.

LimitationLess number of patients, limited follow-up period, subjective scoring system.

REFERENCES

1. Crosby LA, Fitzgibbons T. Computerized tomography scanning of acute intra-articular fractures of the calcaneus. A new classification system. J Bone Joint Surg Am 1990;72:852-9.

2. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg 1952;39:395-419.

3. Sanders R. Intra-articular fractures of the calcaneus: Present state of the art. J Orthop Trauma 1992;6:252-65.

4. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-50.

5. Zwipp H, Tscherne H, Thermann H, Weber T. Osteosynthesis of displaced intra-articular fractures of the calcaneus. Results in 123 cases. Clin Orthop 1993;290:76-86.

6. Sanders R, Fortin P, DiPasquale A, Walling A. Operative treatment in 120 displaced intra-articular calcaneal fractures. Results using a prognostic computed tomographic scan classification. Clin Orthop 1993;290:87-95.

7. Cotton FJ, Henderson FF. Results of fractures of the os calcis. Am J Orthop Surg 1916;14:290-8.

8. Rammelt S, Zwipp H. Calcaneus fractures: Facts, controversies and recent developments. Injury 2004;35:443-61.

9. Soeur R, Remy R. Fractures of the calcaneus with displacement of the thalamic portion. J Bone Joint Surg Br 1975;57:413-21.

10. Tornetta P 3rd. The Essex-Lopresti reduction for calcaneal fractures revisited. J Orthop Trauma 1998;12:469-73.

11. Gülabi D, Sari F, Sen C, Avci CC, Saglam F, Erdem M, et al. Mid-term results of calcaneal plating for displaced intra articular calcaneus fractures. Ulus Travma Acil Cerrahi Derg 2013;19:145-51.

12. O’Farrell DA, O’Byrne JM, McCabe JP, Stephens MM. Fractures of the os calcis: Improved results with internal fixation. Injury 1993;24:263-5.

13. Schepers T, Heetveld MJ, Mulder PG, Patka P. Clinical outcome scoring of intra-articular calcaneal fractures. J Foot Ankle Surg 2008;47:213-8.

14. Singh AK, Vinay K. Surgical treatment of displaced intra-articular calcaneal fractures: Is bone grafting necessary? J Orthop Traumatol 2013;14:299-305.

Table 4: Relation of Bohler’s angle with functional outcomeBohler’s angle MFS (90‑100) MFS (75‑89) Over allPre‑operative 13.67±4.66 11.71±8.49 12.26±7.14Post‑operative 30±11.22 17.95±5.01 21.5±8.63

MFS: Ministeriums für staatssicherheit

Table 5: Comparison of outcome of different studiesSeries Functional outcome (MFS)

Excellent Good Fair PoorTornetta10 50 35 15 0Gülabi et al.11 55 22.5 22.5 0Sanders6 25 41.6 10.8 22.5Present study 26.4 61.6 11.76 0

MFS: Ministeriums für staatssicherheit

How to cite this article: Joshi J, Gupta A, Menon H, Patel M, Lakhani D. Functional outcome of surgically treated sanders Types II, III, IV calcaneal fractures: An observational study. IJSS Journal of Surgery. 2015;2:1-7.

Source of Support: Nil, Conflict of Interest: None declared.

functional outcome of surgically treated sanders types ii...

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