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Severe Calcaneal Fractures

Severe Calcaneal Fractures. Trauma Rounds The Ottawa Hospital Presented by Drs A Liew and M Prud ’ homme-Foster September 11 th , 2012. Overview: Calcaneal fractures. Most common of tarsal bones: 2% of all Articular surface involved in 70% Type IV: 4-28%

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Severe Calcaneal Fractures

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  1. Severe Calcaneal Fractures Trauma Rounds The Ottawa Hospital Presented by Drs A Liew and M Prud’homme-Foster September 11th, 2012

  2. Overview: Calcaneal fractures • Most common of tarsal bones: 2% of all • Articular surface involved in 70% • Type IV: 4-28% • Conversion to fusion as high as 73% in type IV

  3. Outcomes and Expectations • Magnuson (1923) :“saw practically no fractures of the os calcis which did not result in from 30 to 70 percent disability of the foot” • Sanders (2009): “Anatomic reduction of the calcaneus therefore attempts to recreate congruent subtalar and calcaneocuboid joints, to achieve a reduced lateral wall and peroneal tendons, and to restore calcaneal height, hindfoot alignment, and talar declination. Patients should expect to wear regular shoes, to exhibit a normal gait, and to remain pain-free for an extended period of time”

  4. The ‘Ottawa Experience’ • SurveyMonkey(R) 2012, MPF et al. • 3 question survey in plane English: anonymous answers • 16 of 22 staff respondents (73%) over a 2-day period

  5. The ‘Ottawa Experience’ Question 1: Considering the last ten years, how many calcaneal fractures Sanders type 3/4 have you been responsible for managing?

  6. The ‘Ottawa Experience’ Question 2: With regards to management, which of the following have you used?

  7. The ‘Ottawa Experience’ Question 3: Would you consider primary subtalar fusion with reconstruction for a severe calcaneus fracture?

  8. The ‘Ottawa Experience’ Question 3: Would you consider primary subtalar fusion with reconstruction for a severe calcaneus fracture? • Comments Correlated to Volume • But I would refer patient for treatment (1-5) • Not personally, as I would refer, but I might consider it if referral not an option (1-5) • But rarely - rather reconstruct for height and fuse late (6-10) • Never primary arthrodesis they need to have pain as a late outcome (10+) • Maybe, but I haven't seen one yet. And, give it a shot, nothing to lose with ORIF. Sometimes you win big and the patients does well (10+) • Older patient with good skin and low comorbidity risk and wide heel (+10)

  9. Which ones to fuse? • JOT 2003: Review of prospective, randomized trial database, 471 fractures • 44 patients required fusion and were compared to others • SF-36,VAS, OAS, Sanders and Crosby • Primary prognostic determinant: Bohler angle on presentation • <0° ten times more likely to require subtalar fusion than >15° • Sanders type IV 5.5 times more likely than type II • WCB three times more likely than non-WCB

  10. Fusing later… • JBJS 2009: 75 DIACF consecutive series for subtalar fusion for post traumatic OA • Looked at fusion after nonop v. ORIF • Very few Sanders type IV • However was able to show that better outcomes for fusion in ORIF group and easier to achieve height and alignment

  11. Be Careful of Ageism • JBJS 2010: Retrospective 158 fractures, two groups, cut-off 50yoa • 8.98yrs follow-up • Differences: ASA, mechanism of injury, Worker’s comp • Outcome: Older group scored better on all clinical assessments • JBJS 2002: Prospective 471 fractures, stratified groups • 2-8 yrs follow-up • The best patients to treat nonoperative are those who are fifty or older, males and Workers’ comp

  12. New Advances? • Injury 2010: 37 consecutive Sanders type IV treated with primary fuison • AOFAS mean of 75.43 and corresponded to reconstructing Bohler angle • Mean increase of Bohler: 5.26° (normal: 25-40°) • Suggest ‘high clinical effectiveness’: However…

  13. Primary fusion?

  14. Primary Fusion • Foot and Ankle Surgery 2012 • Aim: assess the functional outcome of the primary arthrodesis in the management of comminuted displaced intra-articular calcaneal fractures

  15. Primary Fusion • Lit. search from 1990-2010, eight publications , 128 calcaneus • Follow-up 28 months (12-59) • Time between injury-arthrodesis: 6-22 days

  16. Primary Fusion • Union: 124 of 128 • AOFAS: 77.4 (72.8-88) out of 94 max • 75% good-excellent • Return to work: 75-100% • Wound healing or infection: 21 of 108 (19.4%) • 7 amputations

  17. Primary Fusion • Coleman Methodology: 56 (small and flawed)

  18. Primary Fusion • Only two studies comparing fusion vs fusion after ORIF: slight advantage to primary • One study looking at minimally invasive (Vira) • Current rate of primary fusion: 0.4-15% (5%) • Conclusion:“the process of choosing the best treatment modality for a severely comminuted calcaneal fracture, the primary arthrodesis should receive full consideration”

  19. Evidence on the way…

  20. A blast from the past

  21. Summary • Sanders type IV extremely difficult to manage • 9% good and 91% fair/poor • Much more likely to require fusion • Both nonop and ORIF lead to poor results but fusion better after reconstruction • Better outcomes more often with early fusion • Choose patients based on Bohler angle and risk factors

  22. Background • Outcomes • ORIF • Non op • Fusion • Primary vs delayed • p.808: Thermann et al.28 assessed 17 patients with secondary arthrodesis, and obtained a mean of 69 points on the AOFAS scale, while in cases of primary arthrodesis, they found a mean of 88 points. These extraordinary results have not been established elsewhere. -- Highlighted 2012-09-09 • After ORIF or after non-op • 1. Radnay CS, Clare MP, Sanders RW. Subtalar Fusion After Displaced Intra-Articular Calcaneal Fractures: Does Initial Operative Treatment Matter?Surgical Technique. J Bone Joint Surg Am. The Journal of Bone and Joint Surgery; 2010 Feb. 28;92(Supplement_1_Part_1):32–43. • Vs ORIF • Minimally invasive

  23. What are the results of non-op? • What are the results of ORIF? • Pain and function • Complications • What percentage go on to be fused? • Is fusion late as good as primary fusion? • Which ones will require fusion? • 1. Csizy M, Buckley R, Tough S, Leighton R, Smith J, McCormack R, et al. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma. 2003 Feb.;17(2):106–12. • Showed us that the degree of initial injury (Bohler angle < 0°) was the primary prognostic determinant on long term outcomes • Nonop was 5 times more likely to require fusion • Does fusion type matter? • 1. Csizy M, Buckley R, Tough S, Leighton R, Smith J, McCormack R, et al. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma. 2003 Feb.;17(2):106–12.

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