ClassificationHawkins*Hawkins*----Prognostic Based on Blood FlowPrognostic Based on Blood Flow

Type I non displaced fractures of the

talar neck without dislocation Type II

displaced fracture of the talarneck with sub-luxation ordislocation of the sub-talarjoint

Type III displaced frx of talar neck w/

dislocation of body of talusfrom both subtalar joint andthe ankle joint

Type IV Type III with talonavicular

subluxation or dislocation

**Hawkins LG: JBJS 1970; 52Hawkins LG: JBJS 1970; 52--AA

Type I – undisplacedTruly undisplaced –rotational?

Conservative treatment

Type 2

Subluxed talo-calcanealjoint

Anterolateral ApproachAnterolateral Approach Anteromedial ApproachAnteromedial Approach

Blood supply - talus

Blood supply - talus

Subtalar joint is the key to success

The goal isanatomical reductionof all talar joints

When joints arereduced – thefracture is reduced

Palpation + imageintensifier is veryaccurate

Posterolateralapproach Prone position Incision just lateral to

Achilles tendon Palpate and reduce

subtalar joint Fix with to screws

6 months

5 months5 months

Hawkins sign

Calcaneal fractures

Sanders classificationCT scanning

Bøhler vinkel - GissaneGissanes angle

95°-105°

Reduction is the tricky part Analyze fragments and

plan the reduction Lateral joint Sustentaculum Tuber

Reduce from medial tolateral

Temp fix with multipleK-wires

Evidence – Based DecisionsBuckley et.al. JBJS(A) 2002; 84: 1733-1744

RCT – Operative vs. Nonoperative Treatment ofDisplaced Intraarticular Calcaneal Fractures

559 patients with > 85% 2 year F/UMulticenter (many surgeons)Indications not the same

Marginal better outcome in selectpopulations of patients with surgery

Secondary Subtalar FusionSecondary Subtalar Fusion Nonoperative will result

in 1 pt in six needing asubtalar arthrodesis

Operative will result in1 pt in 30 needing asubtalar arthrodesis

5X more likely ifnonoperative, but notall nonoperativepatients will need afusion

Nonoperative will resultin 1 pt in six needing asubtalar arthrodesis

Operative will result in1 pt in 30 needing asubtalar arthrodesis

5X more likely ifnonoperative, but notall nonoperativepatients will need afusion

Surgical versus nonsurgical treatment ofdisplaced intra-articular calcaneal fracture: ameta-analysis of current evidence base. 2012Aug;36(8):1615-22.

Better recovery of the Böhler angle(P < 0.0001)

Fewer needed increased shoe size(P = 0.0004)

More were able to resume pre-injury work(P = 0.004)

No significant difference regarding theincidence of residual pain (P = 0.49)

Complications to surgery Hardware OIF (experience) Malposition of screws 5% Loss of fixation (böhler)

Infection Superficial 15% / Deep 2%

Sural nerve 10% Compartment syndrome

1-5% or more ?

Who needs operation?

Sanders II + dislocation

Sanders III +1 fragment undisplaced

positive negative

Undisplaced

Smoker

Alcohol abuse

Age > 70 years

Sanders III + dislocation

Sanders IV

Böhler angle 0 or neg.

Short hindfoot

Comorbidity eg. IDDMVarus hindfoot

Take Home Message Talus fracture Reduction is urgent – not fixation Talus neck – talus body – three joints Remember blood supply in sugery

Calcaneus Number of fragments in joint Böhler angle Complicated indication for surgery Results are not fantastic