Calcaneal Fractures — Should We or Should We not Operate?

Abstract

The best treatment for displaced, intraarticular fractures of the calcaneum remains controversial. Surgical treatment of these injuries is challenging and have a considerable learning curve. Studies comparing operative with nonoperative treatment including randomized trials and meta-analyses are fraught with a considerable number of confounders including highly variable fracture patterns, soft-tissue conditions, patient characteristics, surgeon experience, limited sensitivity of outcome measures, and rehabilitation protocols. It has become apparent that there is no single treatment that is suitable for all calcaneal fractures. Treatment should be tailored to the individual fracture pathoanatomy, accompanying soft-tissue damage, associated injuries, functional demand, and comorbidities of the patient. If operative treatment is chosen, reconstruction of the overall shape of the calcaneum and joint surfaces are of utmost importance to obtain a good functional result. Despite meticulous reconstruction, primary cartilage damage due to the impact at the time of injury may lead to posttraumatic subtalar arthritis. Even if subtalar fusion becomes necessary, patients benefit from primary anatomical reconstruction of the hindfoot geometry because in situ fusion is easier to perform and associated with better results than corrective fusion for hindfoot deformities in malunited calcaneal fractures. To minimize wound healing problems and stiffness due to scar formation after open reduction and internal fixation (ORIF) through extensile approaches several percutaneous and less invasive procedures through a direct approach over the sinus tarsi have successfully lowered the rates of infections and wound complications while ensuring exact anatomic reduction. There is evidence from multiple studies that malunited displaced calcaneal fractures result in painful arthritis and disabling, three-dimensional foot deformities for the affected patients. The poorest treatment results are reported after open surgical treatment that failed to achieve anatomic reconstruction of the calcaneum and its joints, thus combining the disadvantages of operative and nonoperative treatment. The crucial question, therefore, is not only whether to operate or not but also when and how to operate on calcaneal fractures if surgery is decided.

Limited Open Reduction and Internal Fixation of Calcaneal Fractures

“…The AOFAS score was chosen even though it has not been validated because it is easy to use, is well established, and has been used in a previous study. 11 The results of the AOFAS score were interpreted as follows: 90-100 = excellent; 80-89 = good; 70-79 = fair; <70 = poor. No other evaluation/scoring system was used.…”

“…A recent systematic review concluded that the majority of displaced, intra-articular fractures are best treated by open reduction and internal fixation, and that less invasive approaches with modern locking fixation have the potential to minimize soft tissue complications with anatomic reduction and stable fixation. 11 In a previous study, the accuracy and maintenance of reduction as well as complications and the ultimate function of patients treated with limited open reduction and internal fixation was validated against a group of patients treated with the extended lateral L-shaped approach. 23 For 24 months we followed a cohort of patients treated with this approach and fixation technique, which was unchanged for 16 years.…”

A comparative study of operative and conservative treatment of intraarticular displaced calcaneal fractures

“…There are studies that have shown better outcomes with non-operative management 9 . Some authors have investigated operative management and got good results 10 – 12 .…”

Management of calcaneal fractures: a case series

“…However, the term 'lovers fracture' is not used again as the circumstances leading to the terminology is not frequent. The decision to manage conservatively or not depends on the nature of the injury, the expertise of the surgeon, the availability of equipment, and the finance of the patient (13). Generally, conservative treatment is offered to those with minimal injury and non-displaced fractures which are extra-articular.…”