Surgical Management of the AcuteCalcaneal Joint Depression Fracture:The VAMC Miami ExperienceThirty-two patients with acute calcaneal fractures presented to the Veterans Affairs Medical Center,Miami, Florida, from October 1985 through March 1994. Twenty-three of these patients wereopen-reduced, and nine were immobilized in a short leg nonweight-bearing cast for a minimum periodof 6 weeks. Of the 23 patients who had open reduction with internal fixation, 74% reported excellentresults, 13% reported good results, 4% had fair results, and 9% had poor results. Of the nine patientswho did not undergo open-reduction internal fixation, three subsequently developed poor results, twodeveloped fair results, three developed good results, and one had no complaints. Of these ninepatients, three ultimately underwent successful hindfoot arthrodesis. This article reviews the currentliterature and discusses the experiences of the Podiatry Service in the VA Medical Center in Miami,Florida, with respect to the surgical management of the acute calcaneal joint depression fracture. (TheJournal of Foot and Ankle Surgery 35(1):2-12, 1996)

Key words: Calcaneal fracture; foot: joint depression fracture

Michael Cohen, DPM, FACFAS1

The calcaneus is the largest and most commonlyfractured tarsal bone (1-3). Articles written pertain-ing to calcaneal depression fractures are voluminous.There have been a multitude of techniques reportedin orthopedic and podiatric literature for the adequatereduction of these technically difficult fractures.These have included and are not limited to fracturereduction with a Bohler's clamp (4, 5), manual reduc-tion (6), posterior facet elevation with percutaneousspike insertion under fluoroscopic assistance (7), openreduction through a medial approach (8, 9), lateralapproach (10, 11), and combined approaches (12, 13).Presently, foot and ankle specialists are becomingbolder with aggressive treatment of these complicatedfractures. Although the pendulum continues to alter-nate between aggressive reduction and conservativetreatment, one must consider the relative contraindi-cations, advantages, and disadvantages of either ap-proach. Furthermore, the long term sequela of theseoften disabling fractures must be appreciated whetherthey are openly reduced or not.

Calcaneal fractures account for 2% of all bodilyfractures and are responsible for 60% of major tarsal

From the Veterans Affairs Medical Center, Miami, Florida.1 Diplomate, American Boards of Podiatric Surgery and Orthope-

dics; Chief, Podiatry Service and Director, Podiatry Surgical ResidencyProgram. Address correspondence to: Veterans Affairs Medical Cen-ter (112D), 1201 NW 16th Street, Miami, FL 33125.The Journal of Foot and Ankle Surgery 1067-2516/96/3501-0002$3.00/0Copyright 1996 by the American College of Foot and AnkleSurgeons

2 THE JOURNAL OF FOOT AND ANKLE SURGERY

Injuries (14). Seventy-five percent result from a fallfrom height, with the average height being 14 feet(15). Calcaneal fractures usually occur between theages of 30 and 50 years, with a male-to-female ratio of5:1 (16, 17). Ten percent of patients with calcanealinjuries have associated fractures of the spine, partic-ularly the lumbo sacral segment (18, 19). Almost 26%have various other extremity injuries (19). Approxi-mately 7% of calcaneal fractures occur unilaterallywith over 98% being closed injuries (20). Economicimplications are quite apparent when one reviews astudy by Nade et aI., who reported that 20% ofpatients with calcaneal fractures may be incapacitatedfor up to 3 years postinjury, and many are still partiallyincapacitated at 5 years postinjury (21).

Some have likened a calcaneal fracture to an eggthat has shattered into multiple fragments, and com-pare fixating this fracture to nailing a custard pie to awall (22, 23). In fact, authors reporting on calcanealfractures have described them as being "serious anddisabling injuries in which the end results are incred-ibly bad" (24), while others view the calcaneal crushfracture as being "rotten" (25, 26). These commentsexhibit the level of frustration that is experienced bysurgeons who have attempted the treatment of suchfractures. In reality, the os calcis has a well recognizedfracture pattern which must be appreciated in order toobtain successful reduction, as well as when consider-ing salvage reconstruction in the chronic pain patient(9, 12, 13).

Anatomy of a Calcaneal JointDepression Fracture

Reduction of the os calcis fracture is based on themechanism of injury. Seventy-five percent of the oscalcis fractures are a result of falling from heights .Therefore, the resulting fracture pattern is relativelyconsistent (12, 15). Displaced intra-articular fracturesare a consequence of axial loading with the rearfoot invalgus postion, thereby placing the tibial vector of forcemedial to the calcaneal point of contact (12).

Essex-Lopressti described the initial fracture line tobe anterior to the posterior facet , and extends mediallyinto the lateral wall, dividing it into an anterior andposterior half (7). A second fracture, the "primary"fracture line, occurs in all displaced fractures and ex-tends from the proximal medial aspect of the medialcortex, distally at least to the level of the initial fracture .This fracture lies centrally on the facet, and duringimpaction the lateral half is driven into the body of theos calcis, producing a "piledriver" effect with explosionof the medial and lateral walls.

The primary fracture line may extend anteriorlythrough either the lateral wall, the calcaneocuboid joint,or medially through the sustentaculum tali. Disruptionof the internal contents of the sustenaculum tali occur ifthe primary fracture line exits medial to the posteriorfacet. In this case , damage will be seen to the interosse-ous ligament and medial capsule. If the fracture lineexits laterally, there will ultimately be two fragments .Fracture reduction will focus on reducing the posteriorfacet. However, if the fracture exits anterolaterallythrough the calcaneocuboid joint, a more complex frac-ture reduction is required. During the instance that thefracture exits medially, isolation of the sustentaculumtali may occur, resulting in a floating fragment. Reduc-tion in this case often requires a limited medial windowto enhance exposure. When attempting reduction, thesurgeon must realize that these generalized fracturepatterns may be disguised with comminution. The dis-tinction can be made between a joint fracture from atongue-type fracture by the presence of a joint depres-sion fracture line which lies behind the posterior facet ,connecting the primary fracture line to the lateral cortex.The result is a loose, depressed portion of the posteriorfacet that is embedded into the body of the os calcis andanteriorly rotated.

The fracture usually concludes with three major frag-ments: 1) the tuberosity fragment (lateral portion of theposterior facet); 2) the superomedial fragment (thesustentacular portion); 3) the distal or anterolateralfragment (located anterior to the posterior facet). Thisfracture line may articulate with the cuboid. The dis-placement and extent of the fracture line and the

FIGURE 1 (A) med ial (B) lateral and (C) anteroposterior views ofthe calcaneal joint depression fracture pattern.

amount of comminution is dependent on the energyabsorbed upon impact (Fig. 1) (12).

The external derangements of the joint depressionfracture pose many long term complications. A widenedheel bone prevents proper shoe fitting and causes im-pingement of the peroneal complex as well as fibularabutment. Furthermore, a loss in Bohler's" angle de-creases the mechanical advantage of the gastrocnemius-soleus complex, and lowers the calcaneal inclinationangle, often functioning as a rigid flatfoot (4). Addition-ally, flattening of the os calcis and displacement of thesubtalar axis transmits eccentrically placed forces ante-riorly to the midtarsal joint which may cause restrictionof motion.

I.ntrinsic derangement includes irregularity of the pos-tenor facet , coupled with angulation restricting propersubtalar joint function, thereby resulting in limitation ofmotion and predisposition for post-traumatic arthritis.Ultimately, a stiff joint places additional stress on themidtarsal complex and ankle, demanding hypermobility

2 Bohler tuber joint angle is formed by the intersection of two linesviewed on a lateral roentgenogram: (1) A line from the highe st pointon the posterior articulating surface to the most superior point of thecalcaneal tuberosity and (2) a line from the highest point on theanterior process of the calcaneus to the highest portion of the posteriorarticulating surface. Normal angles may vary from 25 degrees to 40degrees and should be compared with the contralateral side whendepression fracture is in question.

VOLUME 35, NUMBER 1, 1996 3

FIGURE 2 Case 1 is a 29-year-old white female with a history ofbipolar disorder who suffered a fall from a height after overdosing onantidepressants. Immediate postinjury x-rays reveal a calcanealjoint depression fracture with anterior extension to the calcane-ocuboid joint, (LAT view A) note excessive flattening and comminu-tion visible on calcaneal axial view. (8), Due to emotional instability,psychiatric clearance for ORIF was not obtainable.

precluding it to compensatory degenerative changes.This effect is particularly noted in the often symptomatictransverse tarsal articulation (1). In order to achieve asatisfactory result, the acute surgical treatment mustfocus on both the external and internal derangements,with specific goals in mind. These include restoringheight, length, and width to the os calcis, translation ofthe calcaneal tuber medially under the sustentacularfragment, reapproximation of intra-articular derange-ments, and the repair of any damage sustained by theperoneal complex or other soft tissue abnormalities.During the event that degenerative changes develop inthe tritarsal complex, salvage of the chronic pain patientis simplified if the goals listed have been accomplished.This is made possible by eliminating the need forgeometric reconstruction of the os calcis which oftenrequires complicated osteotomies and extensive bonegrafting, and focusing solely on arthrodesis, thus being afeature which further lends itself to the argument forprimary reduction of the depression fracture.

Radiographic EvaluationUnderstanding the fracture anatomy is imperative to

successful treatment of the intra-articular joint depres-sion fracture. Planning the surgical attack is dependenton concise radiographic analysis. Immediate fracturedetermination is obtained with proper radiography con-sisting of a lateral ankle, medial oblique of the foot,anteroposterior of the foot, calcaneal axial, and Bro-

4 THE JOURNAL OF FOOT AND ANKLE SURGERY

FIGURE 3 lncisional approach providing a lateral window to thefracture pattern.

den's views (27). The lateral view of the ankle illustratesthe loss of calcaneal height as well as the position of theposterior facet. Bohler's angles" (4) are evaluated at thisprojection, along with secondary fracture lines in thetuber (4, 12). The position of the middle facet superim-posed on the sinus tarsi must be examined. The anteriorposterior and medial oblique views of the foot giveadditional information regarding the calcaneocuboidarticulation. The calcaneal axial view demonstrates dis-placement of the primary fracture line, or rotation andshortening of the major fragments. The sustentacularspike that is seen on this view, will exhibit the point ofexit of the primary fracture line (9).

Broden's views are accomplished by placing the x-rayplate behind the ankle with the foot internally rotated sothat the malleoli are parallel to the plate. The beam iscentered on the subtalar joint and angled caudal-ceph-alad 10, 20, 30, 40, and 50 from vertical (27). Thesesequential images offer tangential glimpses of the pos-terior and occasionally middle facet segments. Theauthor has found the 30 to 40 angle most valuable.

The fracture pattern of the os calcis is not alwaysorthogonal to plain film, occasionally hindering the projec-tion of a subtle posterior facet fracture. Plain radiographsalso pose difficulty in properly assessing the sustentacularfragment. Fortunately, due to technological advances inimage techniques, many of the difficulties encountered inconventional radiography are eliminated. Computerizedtomographic (Cf) scanning is indispensable and hasquickly become the standard of practice in imaging thesecomplicated fracture patterns (28-30). The Cf scan is bestaccomplished in two planes, coronal and axial, which aretaken at I-minute intervals (12). The coronal view isoriented perpendicular to the posterior facet and allowsevaluation of the calcaneal height, the depression of thelateral posterior facet fragment, and the status of thesustentacular fragment. The axialview is parallel to the sole

FIGURE 4 Illustration of a Steinman pin in base of the tuber tomanipulate fragments, adapted from Omoto et at. (6). A, Axial viewdepicting depressed facet fragment with lateral transposition of thetuber; B, placing a varus force on the heel and elevating the facet;C, a valgus force coupled with distraction to translate tuber frag-ment medially.

of the foot and assesses the length of the calcaneus,rotation of the major fragments, comminution of themedial and lateral walls, and displacement of the posteriorfacet. It, therefore, becomes clear that two views areessential in obtaining sufficient data for preoperative plan-ning. The Podiatry Service often uses cr scanning in lieuof the Broden views to evaluate the calcaneal joint depres-sion fracture.

While cr scanning allows clearer imaging of thecalcaneal fracture pattern, techniques in cr applicationshave evolved allowing even more distinct interpretations(29, 30). Allan et al. developed a three-dimensionalimaging protocol to recreate the geometry of the frac-ture fragments (29). Standardizing CT scanning tech-niques have inspired a fracture pattern classification thatcould not otherwise be recognized through standardradiography. Lowrie et al. described four fracture pat-terns when the cr gantry is directed 90 to the subtalarjoint. These include an inverted Y, which is the mostcommon type of pattern; a large fragment type wherethe posterior facet fragment is relatively complete, thelongitudinal split involving a vertical fracture linethrough the posterior facet (producing relatively equalfragments), and a comminuted type which representsexplosion of the medial and lateral walls (30).

Patient SelectionSuccessful operative care requires proper patient se-

lection. This is true particularly for the acute fracturepatient. Compliance and cooperation are invaluable.Patients with a psychiatric disorder are of particularconcern, since these fractures occur quite frequently inthis population (12). Noncompliance may obviate thenecessary requirement for nonweight-bearing and earlyrange of motion, thereby jeopardizing the possibilities ofa successful outcome (Fig. 2). This point must also betaken into consideration when assessing individuals witha history of drug or ethanol abuse.

FIGURE 5 Prereduction dorsoplantar and axial views (A, B) of thefractured and depressed posterior facet fragment.

Excessive comminution is a contraindication to openreduction due to the fact that the approach may prove to befutile and unrealistic. Other contraindications include openfractures due to the high risk of infection and furtherdevascularization of the already compromised tissue. Inthese patients, closed reduction may be a more judiciousapproach with the option of future reconstruction, if andwhen indicated.

TimingTiming for surgery is dependent upon 3 factors: 1)

associated injuries which may hold precedence to imme-diate fracture repair; 2) the degree of swelling; and 3)the amount of soft-tissue damage. The initial periodencompassing the first 6-12 hr. is the ideal period oftime for open reduction. Maximal swelling usually oc-curs between the second and third day following injury,and open reduction during this period of time is notrecommended. Control of swelling is essential prior toattempting open reduction and internal fixation (ORIF)and can be insured by utilizing sequential compression,elevation, and ice packs. Repair, however, should not bedelayed longer than 2 weeks, for at this time fracturehealing and hematoma organization will make openreduction considerably more difficult.

Surgical Technique of the Acute Calcaneal JointDepression Fracture

Obtaining proper exposure is key in the reduction ofthe acute fracture. However, due to the multiple fracturepatterns and fragments possible, operative approachesmay provide limited windows to the fracture anatomy.The author prefers a lateral approach by utilizing amodified Ollier's'' incision , which exposes the sinus tarsiand lateral wall of the os calcis (Fig. 3). The incision is

3 An incision placed posterior and parallel to the fibular malleolus,and curving anterior distal to the sinus tarsi.

VOLUME 35, NUMBER 1, 1996 5

FIGURE 6 Axial and anteroposterior views (A, B) demonstratingreduction of the posterior facet , with bone grafting of the voidcreated after elevation of the fragment.

placed 1-2 em inferior and posterior to the fibularmalleolus and curves anteriorly paralleling the plantarcalcaneus, bisecting the calcaneocuboid joint, ending1-2 em distally. The incision is deepened with care takento isolate and retract the sural nerve inferiorly. If acommunicating branch linking it with the superficialperoneal nerve, or medial branch is observed, it issacrificed. The incision is deepened, further exposinganteriorly the extensor digitorum brevis muscle belly,and the inferior attachment of the extensor retinaculum.The extensor digitorum brevis muscle belly is liftedtogether with the subcutaneous tissue and skin as onecomplete unit. Subcutaneous dissection is not carriedout in order to avoid edema by the creation of anunnecessary void. This ensures uncompromised vascula-ture to the skin by maintaining a full thickness flap. Thedissection adequately exposes the anterior superior pro-cess and the calcaneocuboid joint in the event theanterior fracture line exits through this joint. Inferiorly,dissection is carried out subperiosteally exposing thelateral wall of the os calcis, peroneal tubercle, and theposterior facet.

Attention is directed to the fat plug located in thesinus tarsi which is excised. Inspection of the interosse-ous talocalcaneal ligaments is performed. The primaryand anterior fracture patterns are analyzed carefully toprovide information regarding the middle facet and thesustentacular fragment. Any hematoma or fracture frag-ments are evacuated, debrided, and irrigated.

Assessment of the posterior facet can be made with-out obviating the peroneal complex or the calcaneofibu-lar ligament, if still intact. However, compression of theperoneal tendons within the subtalar joint or inferiorsurface of the fibula is frequently observed, therebyindicating damage to the superior peroneal retinaculum.In one particular instance, compression was severeenough to cause partial rupture of the peroneus brevistendon.

Medially, sustentacular entrapment may also occur.Medial tendon impingement has been reported by Ro-

6 THE JOURNAL OF FOOT AND ANKLE SURGERY

FIGURE 7 An artistic rendition of placement of screw plates forstabilization and support showing repair of depressed fragment withplacement of buttress plate.

mash who discovered two cases involving interpositionof the flexor hallucis longus due to the disassociation ofthe superomedial sustentacular fragment (31). Whencoupled with a severely comminuted fracture pattern,visualization of the subtalar joint is difficult . In this case,the peroneal complex must be freed and retractedsuperiorly in order to provide adequate exposure of thesubtalar joint and lateral wall.

At times, a medial exposure technique may be imple-mented as an alternative or ancillary approach. McRey-nolds described a medial approach for reduction of themedial wall which directly accommodated the primaryfracture line (8). Using specifically designed tr iangulartable staples, the medial wall was reconstructed and thetuberosity fragment was translated medially to supportthe sustentaculum tali. This technique corrected rotationand maintained height. Romash modified this methodby using standard staples which were inserted intopredrilled holes (13). Romash and Ross have recom-mended a bi-incisional approach, particularly in theinstance where considerable sagittal plane rotation ex-isted (12, 13).

A medial exposure has the advantages of an addedwindow by allowing direct visualization of the primaryfracture. However, the author feels that in many casesthe risks of a medial approach outweigh the benefits andshould be avoided , when possible. The disadvantagesinclude manipulation of the delicate neurovascular bun-dle, potential scarring of the long flexor tendons, andadditional dissection which may compound postopera-tive morbidity. Furthermore, the calcaneus possesses aweak medial cortical wall which often cannot sustain afixation device (13) . Therefore, this medial approach isavoided when there is excessive comminution or whenthe rotatory translation of the calcaneal tuber can bemanipulated adequately through a lateral incision.

The medial incision is performed at the lower mid-portion of the calcaneus, bisecting and paralleling the oscalcis. The incision is deepened, exposing the laciniate

FIGURE 8 Case 2 is a 58-year-old carpenter who fell off a ladder. Preoperative lateral and axial (A, B) radiographs reveal a calcaneal jointdepression fracture. Preoperative CT scan (C) confirms this diagnosis and demonstrates an "inverted Y" fracture pattern. Immediatepostoperative radiographs consisting of AP. MO, LAT, and axial views (D-G) show position of internal fixation devices . Calcaneal axial ,Broden's, and lateral views (H-J) , taken immediately following removal of implants, reveal re-establishment of calcaneal architecture withexcellent re-alignment of the posterior facet.

ligament and sensory branches emanating from theposterior tibial nerve. The abductor hallucis muscle bellyis visualized and retracted inferiorly, exposing the infe-rior aspect of the calcaneus. The laciniate ligament isincised exposing the contents of the posterior compart-ment which include the long flexor tendon, and neuro-vascular bundle, and are gently tagged and retracted.

Mobilization of these structures is especially required ifthe primary fracture line is located close to the susten-tacular fragment.

Although reduction of the sustentacular fragmentthrough a medial window is not always necessary, it isoften possible to reduce the sustentacular and tuber-osity fragments solely through a lateral approach.

VOLUME 35, NUMBER 1, 1996 7

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FIGURE 9 (Case 3) This is a 55 year old white male who is a rooferand sustained a fall of approximately 18 feet. Preoperative LAT andMO views (A, B) indicate a joint depression fracture of the calca-neus. CT scan (C) illustrates "inverted Y" fracture pattern withblowout of the lateral wall. Lateral displacement of the tuber is welldemonstrated. Post-operative AP and LAT views (0, E) indicatesuccessful reduction.

8 THE JOURNAL OF FOOT AND ANKLE SURGERY

Using this exposure, isolation of the depressed androtated anterior fragment is accomplished with theuse of an elevator. The instrument is inserted beneaththe sustentacular fragment and lifted while the calca-neal tuber fragment is shifted medially and posteri-orly. In the instance that the tuber fragment is difficultto manipulate, a small gauge Steinman pin may beinserted transversely at the base of the tuber fragmentand allowed to exit medially through a stab incision.This method enables the surgeon to leverage the tuberfragment into proper position by placing a varustorque, distracting, then a valgus force, while rotatingit internally (Fig. 4). The maneuver will also aid inelevating the depressed fragment (6).

Attention is then directed to the depressed posteriorfacet. Elevation of this fragment will reveal a vacuole ofimpacted cancellous bone, which usually will not supportthe loose osteochondral fragment when reduced. It is forthis reason that bone grafting is frequently performedafter posterior facet reduction, particularly if the defectis a large one.

Alignment and fixation of the posterior facet is ac-complished by taking advantage of the dense subchon-dral bone located directly beneath its surface. Primaryfixation is accomplished by suspending this fragment tothe sustentacular fragment, usually aimed distal mediallyand directly inferior to the middle facet, particularly ifthe middle facet is floating independently. The posteriorfacet is aligned with a .062" Kirschner wire and fixatedusing Association of Osteosynthesis (AO) principles.

Although frequently small, the posterior facet cangenerally accommodate a 3.5-mm. cancellous screw.Alternatively, the 3.5- to 4.0-mm. cannulated screwsystems have been especially useful in fixating thisfragment by allowing the surgeon to conserve preciousspace. Placing the screw perpendicular to the fractureline is to be avoided due to the potential sagittal rotationof the fragment, unless two screws are used. Otherwise,an obtuse approach is more desirable to obtain a stabletwo-point grab. With this accomplished, the sustentacu-lar fragment is fixated with additional screws. A plate isutilized in the event that there has been a blowout of thelateral wall and a strut is required for a supportivemeasure. Positioning of the plate is applied after bonegrafting. Oftentimes, however, relocation of the facetalong with repair of the primary fracture is adequatewithout the need for plate fixation (Fig. 5). Bone graftsused include freeze-dried corticocancellous bone chips(obtained from the University of Miami Tissue Bank) inan effort to avoid pain and morbidity associated withadditional surgery. However, in the event that acquisi-tion of freeze-dried bone was not possible, cancellousbone has been harvested from the proximal tibial me-taphysis, although a variety of alternate donor sites are

FIGURE 10 (Case 4) This 62 year old white male fractured his calcaneus while trying to leap off a moving vehicle. LAT view (A)demonstratesdepression fracture with extension of anterior fracture line through the calcaneocuboid joints. Axial view (B) clearly demonstrates thesustentacular spike indicating the exit of the primary fracture line. (C) Due to the absence of excessive comminution, the lateral wall wasstable enough to obtain adequate reduction with three 4.0mm cancellous screws.

adequate (Fig. 6). The lateral cortical wall which pos-sesses a shell -like appearance, will envelop the graftwithin the body of the calcaneus. Plating of the lateralwall is facilitated with one-third tubular, "L," "zig zag,"or "T" plates (Fig. 7), after which the anterior fractureline is closely reinspected for application of additionallag screws, particularly if the fracture is intra-articular.In this instance, a floating sustentacular fragment mayresult from such a fracture line which may requireadditional fixation . Proper screw length is necessary toavoid violating the neurovascular bundle and the flexorhallucis longus (FHL) tendon lying beneath the susten -taculum. The fracture lines are reinspected once again,and when proper fracture alignment has been obtained,the surgical goals will have been met.

If used, the transverse manipulation pins are removedat this time, and soft-tissue structures are reapproxi-mated accordingly. Any peroneal tendon damage notedis repaired. The foot is bandaged with sterile fluffdressing, gauze bandaging, and an elastic wrap. A pos-terior splint is applied for 5 days, at which time the firstdressing change is performed and a short leg nonweight-bearing (SLNWB) cast is applied for 2 to 3 weeks. In10-14 days the SLNWB cast is bivalved and active rangeof motion (ROM) exercises are initiated. Partial weightbearing (PWB) begins at weeks 6-8. Radiographs aretaken at biweekly intervals until consolidation is noted.This usually occurs by weeks 10-12, whereby full weightbearing in a short leg walker is facilitated for an addi-tional 2 weeks (Figs. 8-11).

Materials and MethodsFrom October 1985 through March 1994, 32 acute

calcaneal joint depression fractures presented to the VA

Medical Center, Podiatry Service, Miami, Florida. Thepatients' ages ranged from 27 to 68 years , the medianage being 57 years. Twenty-three patients underwentopen reduction with internal fixation , 22 through alateral approach, and one using a bilateral exposuretechnique. The results were classified objectively by thesurgeon under four groups: The first group consisted ofpatients who obtained an excellent result. These patientswere able to return to their pre-injury activities withminimal to no limitations or pain , and did not requirepostoperative prosthetic care to achieve painless ambu-lation (this includes the use of AFOs (Ankle/FootOrthoses), orthoses, or special shoe gear). These pa-tients rarely required the use of NSAlDs, (nonsteroidalanti-inflammatory agents) and were able to return toemployment without application for permanent disabil-ity. The second group consisted of patients with goodresults. The patients had some minor limitation topreinjury activities that required postoperative orthoticassistance in order to achieve pain free ambulation. Thisgroup required occasional use of NSAIDs for paincontrol. The patients experienced minor dull pain afteran extended period of exertion, but were able to returnto their preinjury employment status without request fordisability. The third group of patients consisted of thosewith fair results. These patients reported an inability toreturn to their preinjury activities, experienced moder-ate pain, and required constant use of NSAIDs foranalgesia. The amount of pain and its severity wasdependent upon the amount of exertion (i.e., distance,physical activity, etc.). Additionally, this group of pa-tients were able to return to activities and employmentwith permanent modifications in lifestyle and shoe gear.The fourth and final group consisted of patients with

VOLUME 35, NUMBER 1, 1996 9

FIGURE 11 (Case 5) This is a 66 yearold white male who is a laborer andhad fallen from a height while repairinga roof. Preoperative C-T scanning re-veals longitudinal split fracture patternwith severe comminution, view A-1 &A-2. Repair was achieved with a com-bined approach utilizing a zig zag plateand isolated 3.5 cortical screw secur-ing the posterior facet laterally (B), cal-caneal axial (C) however, drainage wasnoted through a sinus tract 1 yearpostoperatively whereby the fixationdevices were removed and a course ofIV antibiotics begun. Note collapse ofthe subtalar joint requiring debride-ment and eventual fusion (D).

moderate to severe pain. These patients were completelydependent on prosthetic devices, and although theyunderwent extensive physical therapy, they still requiredthe occasional assistance of a crutch or cane. Thepatients in this group frequently requested narcoticanalgesics, and could not return to preinjury employ-ment status without severe restrictions in activity. Thesepatients were considered to have an unsatisfactoryresult.

ResultsOf 23 open reduction internal fixation procedures of

the calcaneus, four complications were noted. There wasdehiscence of the wound margins in two cases, noncom-pliance leading to loose hardware with loss of fracturereduction and Bohler's angle (requiring eventual re-moval and immobilization) in one case, and osteomyeli-tis in the remaining one. The wound dehiscences weremanaged with local wound care and oral antibiotics andboth healed uneventfully. The patient with osteomyelitiswas treated in-house with intravenous antibiotics andrepeated debridements. He was subsequently discharged

10 THE JOURNAL OF FOOT AND ANKLE SURGERY

on oral antibiotics and immobilized until healing hadtaken place. Nine fractures were managed conservativelywith immobilization consisting of nonweight-bearingshort leg casting for 6 to 8 weeks, followed by a walkingcast for a period of 2 to 4 weeks, or until consolidationwas appreciated. Range of motion exercises were imple-mented for the ankle and subtalar joints during weeks 2to 4. Of the nine patients who were treated conserva-tively, surgery was contraindicated in four resulting frompre-existing medical disease, unstable psychiatric condi-tions, and age. Additionally, there were two patients whodeclined surgery.

Using our criteria of 23 patients who were open-reduced, 74% (17) reported excellent results. Thirteenpercent (3) reported good results, 4% (1) fair results,and 9% (2) poor results (Fig. 12). None of theunacceptable results underwent salvage procedures atthe time of this article. Of nine patients treatedconservatively, 22% (2) developed moderate to severepain and had a poor result, 33% (3) developedmoderate pain and were considered fair, 33% (3) hada good result, while 11% (1) had an excellent result.

term results (2.92 years) than conservative management,as opposed to our surgical repair patients who experi-enced a higher success rate (74%) (excellent and good).These results must be read with caution however, as thelongest follow-up is approximately 83 months, added tothe fact that our conservative treatment group wasrather small.

It is imperative to note that the median age in the studywas 57 years. Many of the patients consisted of a popula-tion segment that is quite sedentary. A significant percent-age (35%) consisted of retired patients whose physicaldemands are not as remarkable as the younger more activepopulation segment, hence possibly being an importantfactor in the success rate. Interestingly, a correlation couldnot be made between the extent of injury and outcomewhether open reduced or not. This fact was especiallynoted when 16 additional patients were referred to theVAMC Foot and Ankle Clinic for chronic pain followingconservative treatment of depression fractures. The mag-nitude of pain experienced was not related to the extent ofgross distortion appreciated on radiographs. In fact, someof these patients did not show appreciable subtalar degen-eration until CT scans were performed. A study recentlysubmitted by this facilityindicates that hindfoot arthrodesishas a significantlyhigh success rate, and is a powerful toolin the treatment of the chronic pain patient when per-formed correctly.

4% (1)Fair

r;IlllllWQ_mmttlm.~22% Poo rResults

Group IV

FIGURE 13 Analysis of conservatively treated patients.

74 (1 7)Excellen t Results

Group 1FIGURE 12 Follow-up results of 23 patients undergoing openreduction.

Three out of five poor and fair result patients ulti-mately underwent hindfoot arthrodesis. An unaccept-able outcome was noted in 55% of the conservativecare patients. There were four patients who fit intothe excellent and good categories (11 and 33%, re-spectively) (Fig. 13). These patients were dischargedfrom the clinic.

SummaryLiterature describing the calcaneal joint depression

fracture has been voluminous and dates back to the earlypart of this century. Yet, the debate regarding openversus closed treatment continues and is attributedmainly to the wide variability in reported findings.Recent studies, however, indicate that aggressive treat-ment of these disabling fractures has provided consistentresults, particularly when reduction is anatomical, al-though one must also realize that complications result-ing from open reduction are certainly not uncommon.

When examining the acute fracture in this study,unacceptable outcomes were obtained in approximatelyhalf of the patients who received conservative therapy.The finding may be consistent with Leung et al. (32), whoreported that operative treatment of displaced intra-articular calcaneal fractures produced better medium

References1. Kalish, S. R The conservative and surgical treatment of calcaneal

fractures. J. Am. Podiatr. Med. Assoc. 65:912-926, 1975.2. Sisk, T. D. Fractures of the lower extremity, edited by A. S.

Edmonson and A. H. Crenshaw Campbell's Operative Orthopedics,7th ed., vol. 3, p. 1616. St Mosby-Year Book, St. Louis, 1987.

3. Rockwood, C. A., Jr, Green, D. P. Fractures in Adults. JBLippincott, Philadelphia, vol. 2, Ch. 24, pp. 2103-2130, 1984.

4. Bohler, L. Diagnosis, pathology, and treatment of fractures of theos calcis. J. Bone Joint Surg. 13A:75-89, 1931.

5. Wilson, D. W. Functional capacity following fracture of the oscalcis. Can. Med. Assoc. J. 95:908-911, 1966.

6. Omoto, H., Sakjrada, K, Sugi, M., Nakamura, K. A new methodof manual reduction for intra-articular fracture of the calcaneus.Clin. Orthop. 177:104-111, 1983.

7. Essex-Lopressti, P. The mechanism, reduction technique, andresults in fractures of the os calcis. Br. J. Surg. 39:395-419, 1952.

8. McReynolds, I. S. The case for operative treatment of fractures ofthe os calcis. In Controversies in Orthopaedic Surgery, edited by R.E. Leach, F. T. Hoaglund, and E. J. Riseborough, pp. 232-254, W.B. Saunders, Philadelphia, 1982.

9. Burdeaux, B. D. Reduction of calcaneal fractures by the McRey-nolds medial approach technique and its experimental basis. Clin.Orthop. ReI. Res. 177:87-103, 1983.

10. Palmer, I. The mechanism and treatment of fractures of thecalcaneus, open reduction with the use of cancellous grafts. J.Bone. Joint. Surg. 30A:1-8, 1948.

11. Castellano, B. D., Cain, T. D., Kalish, S. R, Ruch, J. A. Calcanealfractures what could be, reconstructive surgery of the foot and leg.

VOLUME 35, NUMBER 1, 1996 11

Tucker, GA, Podiatric Institute Publishing Co., pp. 155-170. 12,Update 1988.

12. Ross, S. D. K. The operative treatment of complex os calcisfractures. In Techniques in Orthopedics, vol. 2, pp. 55-70, AspenPublishers, Inc., Frederick MD, 1987.

13. Romash, M. M. Calcaneal fractures three dimensional treatment.Foot Ankle 8:180-197, 1988.

14. Cave, E. F. Fractures of the os calcis, the problem in general. Clin.Orthop. 30:64-66, 1963.

15. Slatis, P. K., Kiviluoto, O. Santavirtas, S. Fractures of the calca-neum. J. Trauma 19:939, 1979.

16. Clisham, M. W., Berlin, S. J. The diagnosis and conservative treat-ment of calcaneal fractures, a review. J. Foot Surg. 20:28, 1981.

17. Spector, E. E. Fractures of the calcaneus. J. Am. Podiatr. Med.Assoc. 65:789, 1975.

18. Gage, J. R, Premer, R. Os calcis fractures, an analysis of 37. Minn.Med. 54:169-176, 1971.

19. Rowe, C. R., Sakellarides, H. T., Freeman, P. A., Sorbie, C.Fractures of the os calcis, a long term follow-up study of 146patients. J. Am. Med. Assoc. 184:920-923, 1963.

20. Lindsay, W. R. N., Dewar, F. P. Fractures of the calcaneum. Am.J. Surg. 95:555-576, 1958.

21. Nade, S. M. L., Monahan, P. R. W. Fractures of the calcaneum, astudy of the long term prognosis. Injury 4:200-207, 1973.

12 THE JOURNAL OF FOOT AND ANKLE SURGERY

22. McLaughlin, H. L. Trauma W. B. Saunders, Philadelphia, 1959.23. McLaughlin, H. L. Treatment of late complications after os calcis

fractures. Clin. Orthop. 30:111-115, 1963.24. Conn, H. R. Fractures of the os calcis, diagnosis and treatment.

Radiology 6:228-235, 1926.25. Bankart, A. S. B. Fractures of the calcis. Lancet 2:175, 1942.26. Cotton, F. J. J., Henderson, F. F. Results of fracture of the os

calcis. Am. J. Orthop. Surg. 14:290-298, 1916.27. Broden, B. Roentgen examination of the subtaloid joint in frac-

tures of the calcaneus. Acta Radiol. 31:85-91, 1949.28. Johnson, E. E. Intraarticular fractures of the calcaneus, diagnosis

and surgical management. Orthopedics 13:1091-1100, 1991.29. Allan, S. M., Merhs, D. Ci: Three dimensional analysis of calcaneal

fractures. Foot Ankle 11:254-263, 1991.30. Lowrie, I. G., Finlay, D. B., Brenkel, I. J., Gregg, P. J. Comput-

erized tomographic assessment of the subtalar joint in calcanealfractures. J. Bone Joint Surg. 70B:247-250, 1988.

31. Romash, M. M. Fracture of the calcaneus, an unusual fracturepattern with subtalar interposition of the flexor hallucis valgus, areport of 2 cases. Foot Ankle 13:32-41, 1993.

32. Leung, K. S., Yen, K. M., Chan, W. S. Operative treatment ofdisplaced inra-articular fractures of the calcaneum medium-termresults J. Bone Joint Surg. 75B:196-211, 1993.