Tag Archives: calcaneal fractures

Surgical treatment results of displaced intra-articular calcaneal fracture using a locked nail

by Radomskii Aleksander1, Ryabokon Pavel2pdflrg

The Foot and Ankle Online Journal 8 (2): 4

There is no general agreement for the best surgical treatment of displaced intra-articular calcaneal fractures. The objective of this study was to estimate the outcome of open reduction and internal fixation with locked nail for treatment of displaced intra-articular calcaneal fractures. This prospective study was conducted on twenty seven patients (24 men and 3 women) and 29 calcaneal fractures were stabilized. The average age was 38.7 (18–64). A shortened lateral approach was used to stabilize fractures using screws and a locked nail fixator for maintenance. The following radiological variables were assessed: preoperative and postoperative Böhler’s angle; calcaneal length, height, and width. The patients were evaluated by the AOFAS Ankle-Hindfoot Scale and overall results were 82.5 points at 6 month and 83.7 at 12 month follow-up. In conclusion, open reduction and internal fixation with locked nail is an effective treatment for Sanders 2 and 3 cases of displaced intra-articular calcaneal fractures.

Key words: calcaneal fractures, osteosynthesis, locked nail

ISSN 1941-6806
doi: 10.3827/faoj.2015.0802.0004

Corresponding author: 2Ryabokon Pavel
Postgraduate at the Department of Orthopedics and Traumatology № 2 at Shupyk National Medical Academy of Postgraduate Education.  Bahhovutivska st. 1. Kiev. Ukraine. travmat@ukr.net

1 Professor at the Department of Orthopedics and Traumatology № 2 at Shupyk National Medical Academy of Postgraduate Education.


The management of displaced intra-articular calcaneal fractures remains a significant challenge to orthopedic surgeons and patients [1,2].These fractures are debilitating and have important long-term consequences for patients [1,3,4,5]. The most effective treatment of displaced intra-articular calcaneal fractures is still a matter of debate [1,3,6]. The adverse effects of the lateral extensile approach with plate fixation are the damage to the soft tissues and subsequent wound complications [3,7]. To avoid these soft tissue complications, several minimally invasive methods have been developed [2,7,8]. The aim of this study was to assess the clinical, radiographic, and functional outcomes of patients after locked nail osteosynthesis of displaced intra-articular calcaneal fractures.

Materials and methods

A cannulatedlocked nail and screws is presented forintraosseousosteosynthesis of the calcaneus (Figure1).Locked nailhas a diameter of8mmandfourlengths: 65mm, 70mm, 75mm,80mm.In addition, the core of the nail has threeholesforlocking screws.The two of themintroducedperpendicularto the centralaxis ofthe nail in thehorizontal plane andlocated in the headandtail sectionof the locked nail.The thirdholeisobliqueto the centralaxis ofthe nail at38ºand located in thesagittalplane.The tailof thelocked nailhasa threadedholeslotsfor introduction and attaching navigation systems.This localizationof holesandlockingscrewscreatesstabilityin the frontal, horizontal andsagittalplane.

Therefore, in our opinion, presented locked nail method has several advantages. First, the stability of the posterior articular area provided via direct support by sagittal locking screw. Second, there is a possibility of closed surgery with fluoroscope control. Third, if necessary to undertake open reposition and bone grafting, lateral surgical approach can be shortened and minimized. Fourth, there is no conflict of fixative elements with peroneal tendon and lateral ankle. Fifth, intraosseous placement design reduces the risk of necrotic complications.

The purpose of the current study is to evaluate the results of open reduction and locked nail fixation as a surgical treatment of the displaced intra-articular calcaneal fracture.

Twenty nine displaced intra-articular calcaneus fractures in twenty seven patients were stabilized with open reduction and locked nail internal fixation from May 2011 to December 2014. There were 24 men and 3 women. Their average age was 38.7±11.1 years (18–64). The right calcaneus was fractured in 13 cases and the left side in 16 cases. All cases were closed fractures.

At the emergency department the lateral, axial, and Broden`s radiographs of the fractured calcaneus as well as lateral radiographs of the opposite foot were taken. A pre-operative CT scan was taken in 5 cases. Thirteen cases were classified as a joint depression type and sixteen as a tongue types according to Essex-Lopresti. There were Sanders II type fractures in 16 cases and III type in 13 cases.

Surgical technique

At emergency department of the hospital, the patient’s foot was elevated and placed in posterior plaster splint. In operating room, the patient was placed in lateral position on the side opposite the fractured calcaneus. An ankle or thigh tourniquet was applied. Spinal or peripheral regional anesthesia. In case of the open method of surgery a 6-7cm length arcuate lateral incision was performed. The incision originated behind the lateral malleolus from the point midway between the fibula and Achilles tendon, extended down then turned anteriorly reaching anterolateral corner of the calcaneocuboid joint. A full-thickness flap was developed, the peroneal retinaculum was opened and the calcaneofibular and talocalcaneal ligaments were detached from bone. As the flap was developed proximally, the subtalar joint and the sinus tarsi were exposed. After dissection of remaining capsular tissue and washing out the fracture hematoma, it was possible to inspect the posterior articular facet. Then, the fracture was reduced by elevator and surgical awl under direct visualization. Temporary fixation was performed with several Kirschner wires, the wires were driven through the subchondral region of the posterior articular facet from lateral to medial. Kirschner wires were exchanged for 3.5mm screws as needed for more stable fixation. When elevation of the fragments left a large defect in cancellous bone, autogenous bone graft was used.

There were three navigation systems for locked nail osteosynthesis. The first navigation system was used for reaming channel and locked nail introduction.  Two others were applied for blocking the locked nail with three screws.  Firstly we started an introduction of a guide pin. It was inserted from the middle center point of the calcaneal tuber in the area below the insertion of Achilles tendon attachment and directed towards the center of the calcaneocuboid joint. After this, the X-ray control of the reposition and localization of the guide pin was held. Through aiming pin 8mm cannulated drilling to a predetermined depth and positioning of the locked nail was made. The aiming pin was put out. With the second navigation system locked nail was blocked with two 3.5mm blocking screws horizontally. With the third navigation system locking was performed in the sagittal plane through the oblique hole in the locked nail, thus achieving direct support of the posterior articular facet of the calcaneus (Figures 2,3). Temporary fixation was removed, the tourniquet was released, hemostasis obtained, wound was closured with stitches, bulky dressing was applied, and the extremity was elevated. In the postoperative period, additional immobilization was not applicable, limb elevation and antibiotics were given for 5 days.

It may be possible to perform a closed reduction of the fragments and introduce a locked nail through 1 cm cut and cut points for blocking screws using fluoroscopy.

The patients were followed up for 6-12 months after the surgery. On the radiographs and CT scans, we evaluated: Böhler’s angle; calcaneal length, height, and width.

figure 1 schemat draw

Figure 1 Schematic image of the intracalcaneal location of the locked nail and screws.

Fig 2 later wiev for engl art

Figure 2 Lateral radiograph of the fixed calcaneal fracture with locked nail and screws.

Figure 3 Broden for engl art

Figure 3 Broden’s radiograph of the fixed calcaneal fracture with locked nail and screws.

The severity of subtalar arthritis was graded based on the radiographic appearance according to Paley [5].  The patients were evaluated by a generally accepted AOFAS Clinical Rating System, the Ankle Hindfoot Scale for calcaneal area (100 points total, 90–100 points, excellent; 80–89 points, good; 70–79 points, fair, less than 70, poor).

Statistical Analysis

Continuous variables (patient statistics and radiographic variables) in the form of the mean and standard deviation were summarized.

Categorical variables were expressed by using frequency and percentage.  Student’s t-test was used to compare the differences among preoperative, and postoperative radiographic measurements. The level of significance was set at p < 0.05. All statistical analyses were performed using MS Excel 2003 software.

Results

One patient was lost to follow up. Average AOFAS score at 6 month follow up was 82.5±4.8, there were three excellent (10.7%), eighteen good (64.3%), six fair (21.4%), and one poor (3.6%) results in 28 cases.  For simplicity, the excellent and good cases were rated satisfactory (75.0%), and the fair and poor cases were rated unsatisfactory (25.0%). At 12 month follow up we received  four excellent (14.3%), twenty good (71.4%), three fair (10.7%), and one poor (3.6%), satisfactory 85.7% and 14.3% unsatisfactory results. The mean value was 83.7±5.6.

At both follow up there was no or slight pain at the lateral aspect of heel. It should be noted that this type of pain was the main complaint of the majority of patients after plate osteosynthesis. Pain that was related to subtalar joint arthrosis had been noted in eleven patients. There was implant irritation pain in retrocalcaneal region in five patients. It was due to the locked nail projection beyond the shape of calcaneal bone which led to implant removing after consolidation of the fragments. No patients showed a normal (as at opposite leg) range of motion of the subtalar joint even in case of anatomic restoration of articular surface and lack of arthrosis at follow ups.

A mild restriction at subtalar joint movement was in seven cases, moderate in twenty one cases, marked restriction in one patient. In one patient it is planned to perform a subtalar arthrodesis to consistent walking pain despite good radiographic parameters.

The average preoperative Bohler’s angle was 7.5º±12.2º. (range from -18.3º to 27.9º), and the average postoperative angle was 29.7º±5º (range 22.2º–40º). The mean calcaneal height before operation was 44.0±4.5mm, at follow up 51.2±4.1mm.  The mean calcaneal length at preoperative measurements was 78.0±14.9mm and at follow up it was 80.7±6.3mm. The calcaneal width before operation was 47.2±4.5mm and after surgery was 41.4±4mm. The mean preoperative Böhler’s angle and calcaneal height were significantly increased (P < 0.05) at postoperative follow-up, whereas the mean preoperative calcaneal width was decreased (P < 0.05).  The reduction was graded as nearly anatomical (less than 2 mm residual articular step-off and satisfactory overall alignment) in 26 (89.7%).  The posterior subtalar joint was assessed for subtalar arthritis at 12 month follow up and have been received grade 0 in 23 (82.1%), grade 1 in 4 (14.3%), grade 2 in 1 (3.6%).

Discussion

In the structure of lesions of the musculoskeletal system calcaneus fractures account for 1-2 % of all fractures of the skeleton, and 60 % of all fractures of the foot. Moreover, the vast majority of these fractures occur in the active working age, resulting in significant economic losses [1,2]. Depending on the nature of the damage and energy of the injury there are various types of fractures of the calcaneus. But the most unfavorable is intraarticular, which leads to damage and arthrosis of the talocalcaneal joint. Heel widening results for calcaneofibular ligament impingement syndrome, compression tenosynovitis of the peroneal tendon. Loss of calcaneal height and shape leads to weakening of the gastrocnemius-soleus muscles function, varus deformity of the foot, ankle contractures [1,2,4,7].

The many ways of conservative and surgical treatment of fractures of the calcaneus were reported [1,2,4,8]. The existing conservative methods do not provide anatomic reposition and stable fixation. A long-term immobilization of the foot significantly prolongs rehabilitation and worsens outcome. Therefore, preference is given to the methods of osteosynthesis by plates, screws, needles, and external fixators [1,2]. The majority of surgeons apply a wide surgical exposure for open reposition and plate osteosynthesis, which provides the opportunity for anatomic reduction and rigid internal fixation of the fragments [1]. At the same time the subcutaneous location of a fixative device, soft tissue deficit, additional trauma and significant neurovascular violations by surgical exposure, adverse microbial environment in the 24 % -32% causes the appearance of purulent- necrotic complications [3,7]. In this regard, the search continues for methods of minimally invasive surgery: closed osteosynthesis with arthroscopic control, balloon calcaneoplasty, arthrodesis through minimal surgical approach [2,4,8].

There were first foreign reports of minimally invasive osteosynthesis for fractures of the calcaneus with locked nail [9]. But the works in this direction have been few and in Ukraine have not yet carried out [10]. The present study was conducted with the purpose to delineate the role of locked nail osteosynthesis in the management of intraarticular calcaneal fractures.

Conclusion

The surgical treatment with locked nail fixation of the calcaneal fragments has proved to be simple, easy, safe, and adequate for management of displaced intra-articular calcaneal fractures. Presented locked nail method of has several advantages: the stability of the posterior articular area provided via direct support by sagittal locking screw, there is a possibility of closed surgery with fluoroscope control, in case of open reduction and bone grafting, lateral surgical approach can be shortened and minimized, there is no conflict of fixative elements with peroneal tendon and lateral ankle, reduced the risk of wound necrotic complications.

It is need to continue investigations in presented method of intracalcaneal locked nail osteosynthesis to improve outcomes for patients with articular fractures of heel bone, improve quality and reduce the invasiveness of surgical treatment of such patients.

References

  1. Bondì R, Padua R, Bondì L, Battaglia A, Romanini E, Campi A. Treatment of calcaneal fractures: available evidence. J Orthopaed Traumatol. 2007; 8: 36-41. link
  2. Schepers T. Displaced Intra-articular Fractures of the Calcaneus with an emphasis on minimally invasive surgery. Surgery and Traumatology. Erasmus MC: University Medical Center Rotterdam. 2009. link
  3. Chechik O, Rosentha R, Salai M, Steinberg E, Tenenbaum S, Thein S. Outcome and complications of surgical and non-surgical treatment of calcaneal fractures. J.Orthopaedics. 2011; 8(4):12. link
  4. Mauffrey C, Bailey GR, Hak DJ, Hammerberg ME. Percutaneous reduction and fixation of an intra-articular calcaneal fracture using an inflatable bone tamp: description of a novel and safe technique. Patient Safety in Surgery.2012; 6:6. link
  5. Paley D, Hall H. Intra-articular fractures of the calcaneus. A critical analysis of results and prognostic factors. J Bone Joint Surg Am. 1993; 75(3): 342-354. PubMed
  6. Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M et all. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. BMJ. 2014;24:4483 PubMed
  7. Koski A. Postoperative wound complications after internal fixation of closed calcaneal fractures: a retrospective analysis of 126 consecutive patients with 148 fractures. Scandinavian Journal of Surgery.2005; 94: 243-245. PubMed
  8. Kopp L, Obruba P, Mišičko R, Edelmann K, Džupa V. Arthroscopically-assisted osteosynthesis of calcaneal fractures: clinical and radiographic results of a prospective study. Acta Chir Orthop Traumatol Cech. 2012; 79(3): 228-232. PubMed
  9. Goldzak M, Mittlmeier T, Simon P. Locked nailing for the treatment of displaced articular fractures of the calcaneus: description of a new procedure with calcanail. Eur. J. Orthop. Surg. Traumatol. 2012; 22(4): 345-349. PubMed
  10. Radomśký OA, Riabokoń PV. Sposib metaloosteosyntezu vnutrišniosuhlobovych perelomiv pjatkovoji kistky blokovanym stryžnem ( poperednie povidomlennia). Travma. 2013; 14: 82-84. PubMed

Avulsion Fracture of the Calcaneal Tuberosity: A soft tissue complication from delayed treatment

by M. Radzilani MBChB1 , E. D’Alton MBChB,(Pret), MMed (Orth)2, R.G Golele, MBChB (Natal), MFGP (SA), MMed (Orth), FCS Orth (SA)3

The Foot and Ankle Online Journal 3 (6): 1

Avulsion fractures of the calcaneal tuberosity are rare extra-articular injuries that usually occur indirectly from forced ankle dorsiflexion particularly in elderly females. Direct trauma to the calcaneal tuberosity is an infrequent cause particularly in young adults. Failure to treat these injuries urgently with open reduction and internal fixation may result in soft tissue complications. We review the literature and present a case report in which soft tissue complications occurred after a direct traumatic avulsion fracture of the calcaneal tuberosity occurred due to delayed treatment.

Key words: Calcaneal avulsion fracture, calcaneal tuberosity, heel fracture.

Accepted: May, 2010
Published: June, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0306.0001


Avulsion fractures of the calcaneal tuberosity are rare extra-articular injuries. [1] They usually result from forced ankle dorsiflexion. [2] Direct trauma to the calcaneal tuberosity is an infrequent cause. [3] Other fractures are due to strong concentric contraction of the gastrocnemius-soleus complex with the knee in full extension during sprinting4, or as a neuropathic fracture in patients with diabetes mellulitis. [2,3] Calcaneal fractures account for 1.2% of all fractures, of which 25% to 40% are classified as extra-articular fractures. [5] Avulsion fractures of the calcaneal tuberosity comprise only 1.3% to 2.7% of calcaneal fractures. [5,6] The peak incidence is in females in their seventh decade as a consequence of diminished bone mineral density. [1,7,8,9]

Most calcaneal fractures are closed injuries that are treated non-operatively, or if treated operatively, surgery is delayed to allow the soft tissues to recover and lower the incidence of incisional complications. [10] This delayed approach in calcaneal tuberosity avulsion fractures can lead to skin necrosis and severe wound complications. [10]

We present a male patient who presented with avulsion fracture of the calcaneal tuberosity due to direct trauma to the calcaneal tuberosity and subsequently developed severe soft tissue complications due to delayed treatment.

The purpose of this report is to emphasize the comparative rarity of tuberosity avulsion fractures of the calcaneus particularly those that are due to direct trauma and to highlight that this subset of calcaneal fractures should be treated urgently to avoid soft tissue complications.

Case report

A 37 year old male patient was assaulted on his left heel with a steel rod 7 weeks before presenting to our center. He had sustained a closed injury, which was initially treated with a plaster of Paris (POP) cast. He then complained of persistent pain inside the plaster cast. Upon removal of the cast, an open wound was identified. The wound was dressed as an outpatient for about 6 weeks before referral. He presented to us with a septic wound, heel boss deformity and a visible bone fragment through the wound. (Fig. 1) He was unable to plantarflex the ankle against resistance. Plain radiograph examination revealed an open beak type fracture or avulsion fracture of the posterior calcaneus as shown in figure 2. Consent was obtained for photographs and documentation.

Figure 1   Left posterior heel boss deformity and a wound with a bone exposure.

Figure 2  Pre-operative radiographs of an open beak type fracture of  posterior calcaneal tuberosity.

Wound cultures revealed staphylococcus aureus, which was sensitive to cloxacillin. The sepsis was treated for 2 weeks with suction drainage and intravenous cloxacillin until the wound was healed. During this time, the ankle was immobilized with an ankle orthosis with a limiting upstop. After the wound had healed and blood markers indicated that the infection was eradicated, open reduction and internal fixation of the fracture was performed. Post-operative radiograph is shown in figure 3. After two weeks the surgical wound was healed and a below knee cast was then applied in plantarflexion for 8 weeks.

Figure 3  Post-operative radiograph following open reduction and internal fixation of the avulsion fracture.

After 12 weeks, he was allowed to fully weight bear when there were signs of bone union radiographically. He was then referred to physiotherapy for rehabilitation with an emphasis on Achilles tendon stretching.

Anatomy

Surgical Anatomy reveals variable insertion of the Achilles into the posterior tuberosity of the calcaneus. (Fig. 4) These anatomical variations have been confirmed surgically by various studies. [11,12,13,14]

Figure 4   Different anatomic insertions of the Achilles tendon. (Reprint permission granted by Beavis, et al., and Foot & Ankle International Publishers6).

Neonates have a thick, continuous sheet of fibers connecting the Achilles tendon and the plantar fascia. [15] With age, the continuity between these two structures diminishes and the retrocalcaneal bursa adjacent to the tendon Achilles insertion become calcified, altering the actual zone of tendon attachment. [6,15] These age-related changes to the Achilles tendon, combined with diminished bone density, explain an increased incidence of calcaneal tuberosity avulsion fractures in the elderly, particularly females. [2,6,7,9,16]

Pathogenesis

The posterior skin of the heel is thin with precarious blood supply. [10] The ankle initially assumes a position of maximal plantarflexion as in falling from a height. In this position the force from a loaded Achilles tendon is transmitted to the calcaneal tuberosity, and to the plantar fascia by a series of highly oriented trabeculae. [6,16] When the gastrocnemius-soleus complex contracts which occurs after a low impact fall, sudden forced dorsiflexion occurs, pulling the tendon Achilles and causing avulsion of a fragment of bone. The size of the avulsed fragment will depend on the position of the foot during impact. During pronation, the whole tuberosity is involved whereas only a part of the tuberosity is involved during supination.

The superior fragment is displaced upwards, presumably due to the pull of the Achilles tendon, and rotated so that the postero-superior border moves upwards and the postero-inferior edge moves posteriorly, compressing the thin skin at the back of the heel. The fragment hinges on its anterior apex as it displaces so that a fracture, which had minimal displacement anteriorly, is often significantly displaced posteriorly, potentially giving rise to a heel boss, pressure necrosis and formation of an ulcer as in our case.

This phenomenon explains the disability resulting from so-called ‘undisplaced’ fractures. [9] Mechanisms of injury and possible etiologies has been described as shown in Table 1. The risk factors that may contribute to calcaneal tuberosity fractures are described in Table 2.

Table 1  Various mechanisms of avulsion fracture injury associated with possible etiologies as described in the literature.

Table 2  Risk factors that can contribute to calcaneal avulsion fractures as described in the literature.

Classification

In older reviews of the literature, two types of tuberosity avulsions were distinguished into those that do not involve the insertion of the Achilles tendon (“beak” fracture) and those that do involve the insertion of the Achilles (avulsion fracture). [22] It is currently thought that these 2 fractures are the same entity and are due to variations in the insertion of Achilles tendon. [11,12] Beavis, et al., has recently proposed a classification system incorporating these two previously described fractures patterns in the literature and one they described themselves. [6] (Table 3)

Table 3 Three types of classifications describing calcaneal avulsion fractures. (with permission granted by Beavis, et al., and Foot & Ankle International Publishers6)

Discussion

Avulsion fractures of the calcaneal tuberosity are rare. [1,2,3,4,5,6,11,13,17] They have been classically described as occurring from indirect trauma produced by falls in which the patient lands on the foot, causing dorsiflexion, with resulting Achilles tendon tension leading to an avulsion. [1,2]

Direct trauma to the calcaneal tuberosity, as in our case, is an infrequent cause of this type of fracture. [4,14,17,18] Malgaigne described avulsion fractures of the tuberosity of the calcaneus as early as 1843. [23] Management and treatment is often dictated by the age, health and functional demands of the patient as well as degree of separation of the fracture fragments. With minimal or no displacement (≤1 cm), conservative treatment either in an equinus cast or a functional boot has yielded satisfactory results. [7] This is accomplished by treatment in a short-leg non-weightbearing equinus cast for 6 to 12 weeks until radiographic union is confirmed. The patient is then gradually brought out of equinus and weight bearing is increased.

Complications after non-operative treatment of calcaneal tuberosity fractures include: skin necrosis, Haglund’s deformity and loss of plantarflexion power. In displaced fractures, skin necrosis as a result of pressure from the underlying fragment is significant cause for concern.

It should be remembered that the soft tissue overlying the Achilles tendon and calcaneal tuberosity is thin with a precarious blood supply. For these reasons these fractures should be treated as emergencies with open reduction and internal fixation. [10]

Methods of fixation include suturing of the avulsed bone fragment, suture anchors, tension band wiring and screw fixation as performed in the present case report. [6,7,9] The choice of technique depends on the size of the avulsed bone fragment and the degree of osteopenia. Screw fixation has been advocated; however it should be kept in mind that most of these fractures are insufficiency fractures. Screw purchase in the bone is poor and healing takes longer to occur.

A better method of fixation would be tension band wiring as described by Brunner and Weber. [24] The fracture is then protected in a short-leg equinus cast for six to eight weeks non-weight bearing until there is radiological evidence of bony union. After union, an ankle orthosis with a limiting upstop is issued for up to one year. Union in these fractures has been reported in the literature from ten weeks to a year. [3,6,7,9] Neuropathic fractures takes longer to heal compared to traumatic fractures in young adults. [3,19,20]

Calcaneal fractures have a high incidence of skin and soft tissue injury. Fracture blisters and deep contusion are common and play an important role in decision-making regarding treatment. Most calcaneal fractures are treated non-operatively, or if treated operatively, surgery is delayed for 2 to 3 weeks to allow the soft tissues to recover and lower the incidence of incisional complications. This delayed approach in calcaneal tuberosity avulsion fractures can lead to skin necrosis and severe wound complications. [10]

Soft tissue problems in avulsion fractures of the calcaneal tuberosity have been known for decades. The case that Rothberg described in 1939 had a superficial infection postoperatively. [1] Dieterle noted soft tissue impingement by the fracture fragments in his classical description of “open-beak” type of calcaneal tuberosity fracture in 1940. [25]

Arner, et al., showed associated rupturing of a small medial part of the Achilles tendon proximal to an avulsed bony fragment in all of the three cases of avulsion fractures of the calcaneal tuberosity that they reported. [17]

Protheroe drew attention to the risk of pressure necrosis of skin overlying displaced fragments and he advocated the need for early operative correction to prevent skin damage. [12] Lowy also described one of his four cases he reported in 1969 which was marred by a persistent sinus which did not heal for 9 months after surgical intervention. [11] Lyngstadaas made mention of the fact that the Achilles tendon may be damaged when it runs over the sharp fragments of an avulsed bone in a poorly repositioned beak. [14] He advocated surgery for this type of soft tissue threatening fractures although necrosis developed on the incision wound of one of the two patients he treated surgically due to what he described as poor circulation.

Cooper, et al., reported on a case of an open fracture of calcaneal tuberosity due to a gunshot injury. The patient was treated with wound debridement, open reduction and internal fixation and intravenous antibiotics as an emergency. The patient went on to unite with no disability. [4] Recently, Hess, et al., reported on three cases of avulsion fractures of the calcaneal tuberosity, which developed soft tissues complications because of delayed surgical intervention. They concluded that the only way to prevent these complications is to reduce and fix the fracture expediently, thus decompressing the skin. [10]

In1980, El-Khoury, et al., described neuropathic calcaneal tuberosity fractures in diabetic patients. They coined the name calcaneal insufficiency avulsion fractures for these fractures. Of importance is the fact that calcaneal insufficiency fractures have high incidence of complications including that of soft tissues. [3,19,20]

Review of this literature supports that a delayed approach in avulsion fractures can lead to skin necrosis and severe wound complications. The initial evaluating physician must therefore recognize these signs to get these injuries treated early.

Signs of skin at risk at presentation are blanching and lack of capillary refill. [10] These are followed by overt skin necrosis, tissue breakdown and infection as in our case. All the complications in our case may have been prevented if more expedient treatment was given on presentation at the referral hospital.

Conclusion

Tuberosity avulsion fractures are rare, particularly those due to direct trauma. They represent a subset of calcaneal fractures that should be addressed urgently to avoid complications, particularly skin breakdown and subsequent sepsis. The initial evaluating physician must recognize the signs of skin at risk so that treatment can be offered urgently. Non-operative treatment has been shown to yield poor results. The golden standard is early surgical intervention when indicated.

References

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2. Heckman JO. Fractures and dislocations of the foot. In: Rockwood CA, Green DP, Bulchoz RW, Heckman JO (editors). Rockwood and Greens Fracture in Adults. Volume 2, 4th ed. Philadelphia: Lippincott-Raven 1996: 2332-2333.
3. Biell III WC, Morgan JM, Wagner WF, Gabriel R. Neuropathic calcaneal tuberosity avulsion fractures. CORR, 1993 269 (11): 8-13
4. Cooper D.E, Heckman J.D. The heel of Achilles: Calcaneal avulsion fracture from a gunshot wound. American Orthopaedic Foot & Ankle Society 1989 9 (4).
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6. Beavis RC, Rouke K, Court-Brown C. Avulsion fracture of the Calcaneal Tuberosity. Foot Ankle Int 2008 29: 863-866.
7. Robb CA, Davies MB. A new technique for fixation of calcaneal tuberosity avulsion fractures. Foot Ankle Surgery 2003 9 (4): 221-224.
8. Stockenhuber N, Wildburger R, Szyszkowitz R. Fractures of the os calcis. Current Orthopaedics 1996 10: 230-238
9. Sqiures B, Allen P.E, Livingstone J, Atkins R.M. Fractures of the tuberosity of the calcaneus JBJS 2001 83B: 55-61.
10. Hess M, Booth B, Laughlin RT. Calcaneal avulsion fracture: complications from delayed treatment. Am Journ Emergency Medicine 2008 26 254: El-254e4.
11. Lowy M. Avulsion fractures of the calcaneus. JBJS 1969 51B 494-497.
12. Protheroe K: Avulsion fractures of the calcaneus JBJS 1969 51B: 118-122.
13. Bierwag K. Avulsion fractures of the calcaneus International Surgery 1970 54: 424-427.
14. Lyngstadaas K: Treatment of Avulsion fractures of the Tuber calcanei. Acta Chir Scanda 1971 137: 579-581.
15. Snow SW, Bohne WHO, DiCarlo E. Anatomy of the Achilles tendon and plantar fascia in relation to the calcaneus in various age groups. Foot Ankle Int 1995 16 (7):418-421.
16. Milz S, Rufai A, Buettner A, Putz R, Ralphs JR, Benjamin Met al: Three-dimensional reconstructions of the Achilles tendon insertion in man. J Anat 2002 200:145-152.
17. Amer O, Lindholm A. Avulsion fracture of the os calcaneus. Acta Chir Scand 1959 117: 258-260.
18. Essex-Lopresti P. Mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg 1952 39: 395-419.
19. El-Khoury GY, Kathol MH. Neuropathic fractures in patients with diabetes mellitus. Diagnostic Radiology 1980 134: 313-316.
20. Kathol MH, El-Khoury GY, Moore TE, Marsh JL. Calcaneal insufficiency avulsion fractures in patients with diabetes mellitus. Musculoskeletal Radiology 1991 180 (3): 725-729.
21. Martini F, Kremling E, Sell S. Bilateral a traumatic avulsion fracture of calcaneal tubercle in osteomalacia during fluoride therapy. Acta Orthop Scand 1999 70(1): 91-92.
22. Rowe CR, Sakellarides H, Freeman P, Sorbie C. Fractures of the os calcis. A long follow-up study of 146 patients. JAMA 1963 184: 920.
23. Schepers T, den Hartog D, Abida Z. Posterior capsular avulsion fracture of the Calcaneus: An Uncommon Alvusion Fracture. J Foot & Ankle Surgery 2007 46 (5): 409-410.
24. Brunner CF, Weber BG. Special Techniques in Internal Fixation. Belin: Springer-Verlag; 1982, pp16-53.
25. Dieterle JO. A case of so-called “open-beak” fracture of the os calcis. JBJS 1940 22A: 740.


Address correspondence to: M. Radzilani MBChB, Registrar, Department of Orthopaedics, Dr George Mukhari Hospital, Pretoria. Medunsa
0204. Tel: 012-521 4005, Fax: 012-521 4029, E-mail: mpho@ul.ac.za.

Registrar, Department of Orthopaedics, Dr George Mukhari Hospital, Pretoria.
Consultant, Dr George Mukhari Hospital, Pretoria.
Professor and Head of Department Orthopaedics Surgery, University of Limpopo (Medunsa Campus).

© The Foot and Ankle Online Journal, 2010

Incorporating Platelet Rich Plasma and Platelet Poor Plasma into Open Reduction Internal Fixation of Closed Calcaneus Fractures to Reduce Wound Complication: A Case Study

by Travis A. Motley, DPM, FACFAS1 , John Randolph Clements, DPM, FACFAS2 ,
J. Kalieb Pourciau, DPM3

The Foot and Ankle Online Journal 2 (11): 1

Background: Calcaneal fractures are high energy injuries. There is some debate with the advantages and disadvantages of treating calcaneal fractures with open reduction and internal fixation based on surgical complication rates.
Methods: We describe the management of 12 patients who presented to our emergency department with 14 closed intra-articular calcaneal fractures (7 Sanders Class III fractures, 7 Sanders class IV fractures). These 14 fractures were treated with open reduction and internal fixation. We describe a technique using platelet rich plasma and platelet poor plasma in the closing of the soft tissues after open reduction of calcaneal fractures.
Results: While complications with open reduction of calcaneal fractures include poor wound healing and infection and can range between 26 and 60 percent, we observed no complications in our small series.
Discussion: Wound complications are the most common and potentially threatening consequence of open reduction and internal fixation of calcaneal fractures. The purpose of this case study is to offer the addition of platelet rich plasma (PRP) and platelet poor plasma (PPP) in the treatment of these complicated injuries. The study also attributes the low complication rate to application of pre-operative bulky Jones type splinting, appropriate surgical timing, pre-operative intravenous antibiotic administration, extensile lateral subperiosteal approach and “hands off” retraction. As well as low profile hardware, drain placement, layered closure with Algower-Donati suture technique, surgeon experience and appropriate post-operative bulky splinting. Our series matched that of previous studies without a single wound complication.

Key Words: Trauma, calcaneal fractures, Algower-Donati suture technique, platelet rich plasma (PRP), platelet poor plasma (PPP).

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: October, 2009
Published: November, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0211.0001


The calcaneus is the most commonly fractured tarsal bone constituting 60% of all major tarsal injuries, but only 2% of all fractures of the body. [1] Calcaneus fractures are high energy injuries [2] and most commonly occur with a fall from a height. [1]

A study by Lance, et al.,[3] has recorded calcaneal fractures from falls ranging three to fifty feet with an average of 14 feet. There is debate over the appropriate treatment for closed calcaneal fractures. The majority of this debate deals with complication rates and functional outcomes of conservative versus surgical management.

Complications of open reduction internal fixation (ORIF) include, but are not limited to, wound complications (dehiscence, hematoma, erythema, cellulitis, and infection), thromboembolism (deep venous thrombosis and pulmonary embolus), malreduction, compartment syndrome, nerve conditions (entrapment, numbness, reflex sympathetic dystrophy), osteomyelitis, and shoewear modifications. Subsequent operations may be required such as fasciotomy, secondary arthrodesis, peroneal nerve neurolysis, hardware removal, exostectomy, and irrigation and debridements for deep surgical site infections. [4,5] Several predisposing factors contribute to wound complications. Furthermore, the Sanders classification [6] can be predictive of complication rates. A previous study reported Sanders Class II calcaneal fractures have an overall complication rate of 27%, Class III fractures are 26%, and Class IV fractures are 60%. [4] The overall complication rate with ORIF of all closed calcaneal fractures is between 0% and 25% with wound complications being between 0% and 16%. [4,5]

Soft tissue and bone healing are mediated by a cascade of intra- and extracellular events. These events are regulated by signaling proteins and specific healing stages. Wound healing has three overlapping stages: inflammation, proliferation, and remodeling. Inflammation is the initial response to tissue injury. The main goal of the inflammatory phase is to provide rapid hemostasis and begin the sequence of events that leads to regeneration of tissue. During the proliferative phase, the damaged, necrotic tissue that is being removed via phagocytosis starts to be replaced with living tissue that is specific to the local tissue environment. During remodeling, the newly generated tissue reshapes and reorganizes to more closely resemble the original tissue. [7]

Platelets play a prominent role as one of the first responders during the acute inflammatory phase. In response to tissue damage, platelets are activated resulting in the formation of a platelet plug and blood clot for hemostasis. The alpha granules of activated platelets contain numerous proteins that influence wound healing. These include platelet derived growth factor, transforming growth factor, insulin-like growth factor, and Factor V, among others. In the presence of calcium, Factor V binds to activated factor X to produce prothrombin activator which converts prothrombin to thrombin. Thrombin then converts fibrinogen to fibrin which binds to platelet surface receptors. This activates another series of factors which are involved in activating factor X via the intrinsic pathway. [7] These proteins from platelet degranulation are partly responsible for cellular chemotaxis, proliferation, and differentiation. This includes removal of tissue debris, angiogenesis, establishing the extracellular matrix, and regeneration of the appropriate type of tissue.

Platelet rich plasma (PRP) is, by definition, a volume of the plasma fraction of autologous blood having a platelet concentration above baseline. [8] Therefore, PRP has the full complement of clotting factors and higher concentration of platelets. The portion of plasma that remains deficient in platelets is known as platelet poor plasma (PPP). PPP has clinical roles as fibrin sealant for hemostasis. Platelet concentrations in PRP range from 2 – 8.5 times that of normal plasma. [7]

Methods

Each patient enrolled in our study was stabilized by one of the three authors in our emergency department. The optimal time for operation was determined by soft tissue indicators: absence of fracture blisters, positive skin wrinkle test, and restoration of elastic properties within the area of incision. Preoperatively, all patients received one gram of Cephalexin, or one gram of Vancomycin if patient had an allergy to penicillin, intravenously 30 minutes prior to the procedure.

Patients were placed in a lateral decubitus position depending on the operative side. A pneumatic thigh cuff was used for hemostasis. The operative foot was supported with a Seattle pillow. The operative leg was then prepped and draped using aseptic technique. The leg was elevated and exsanguinated and the tourniquet was then inflated. A surgical marking pen was then used to draw an L-shaped lateral extensile incision over the lateral aspect of the calcaneus as to maximally preserve the blood supply to the lateral subperiosteal flap as described by Borelli. [9] The horizontal arm was 2 cm superior to the plantar fat pad, the vertical arm of this incision was 1 cm anterior to the Achilles tendon. Each arm of the “L” measured approximately 8 cm in length. The incisions were initially made to the level of the bone. The subperiosteal flap, including the peroneal tendons and the sural nerve, was elevated from the lateral wall of the calcaneus superiorly and retracted with Kirschner wires in the fibula, talus, and cuboid. (Fig. 1) This allowed visualization of the lateral calcaneal body, the calcaneocubiod joint and the subtalar joint.

Figure 1 Extensile lateral approach with Kirschner wires retracting full-thickness skin flap.

After reduction of the articular surfaces, calcaneal body and the lateral calcaneal wall, a low profile titanium perimeter plate and screws (ACE-Depuy®, Warsaw, Indiana) was utilized for fixation.

The wound was copiously irrigated with normalized saline using bulb syringe. A 4-mm flat Jackson-Pratt facial drain was then placed exiting dorsally and sutured into place. Next, PRP derived from the Gravitational Platelet Separation System (GPS® III, Biomet®, Inc., Warsaw, Indiana) was then applied to any body defects and the operative field. The wound was then carefully closed in layers using 2-0 Vicryl (Ethicon®, Johnson & Johnson, Inc., Somerville, New Jersey) for deep tissue, 3-0 Vicryl (Ethicon®, Johnson & Johnson, Inc., Somerville, New Jersey) subcutaneously, and 4-0 Ethilon (Ethicon®, Johnson & Johnson, Inc., Somerville, New Jersey) to reapproximate the skin using the horizontal Allgower – Donati suture technique. [10] (Fig. 2)

Figure 2 Closed extensile lateral approach with Allgower-Donati suture technique. Drain exit site is beyond region of the elevated flap.

Platelet poor plasma from the GPS® III system was then applied above the incision. The wound was bandaged with sterile gauze, kling, and a bulky Curity™ Lakeside™ cotton roll (The Kendall Company, Boston, Massachusetts) compressive posterior splint. The tourniquet was deflated and there were typical hyperemic responses to all the digits. Patients were admitted for postoperative pain management. Drain output was recorded until it produced 30 cc or less in 24 hours. Then, the drain was removed. All patients received one gram of Cephalexin every eight hours or one gram of Vancomycin every 12 hours post operatively until discharged.

Patients were discharged home when their pain was managed appropriately with oral medication. Utilizing this technique, none of our patients had wound complications. Each patient healed the surgical site without incident.

Results

We report on open treatment of 14 calcaneal fractures from 12 patients. Thirteen of the fourteen were sole ORIF of intra-articular calcaneal fractures. One of the fourteen had a primary subtalar joint arthrodesis in addition to reduction of the calcaneus. This patient was included in the study because the surgical approach and timing resembled the other patient who received ORIF. Eleven patients were male, one was female. One patient sustained bilateral injury, and received bilateral repair. Ten of our patients had no pertinent past medical history. One male had a past medical history of transient ischemic attacks, hypertension, and hypothyroidism. One female had a history of numerous psychiatric disorders. Fifty percent (6 of 12) of our patients had social histories significant for tobacco use. There were seven right and seven left calcaneal fractures. Average follow up time period was 11.4 months (range 7-18 months). Average patient age was 35.25 (range from 21 – 69). There were no wound complications in our series utilizing our technique.

Discussion

Calcaneal fractures are high energy injuries with reported complications after ORIF of 0 – 25%.4,5 There is still debate regarding ORIF compared conservative treatment of closed calcaneal fractures based on these complications. In a prospective randomized trial comparing open reduction and internal fixation with non-operative treatment, Howard, et al., [4] reported complication rates of 25% in ORIF of 226 intra-articular calcaneus fractures.

This was then subcategorized into 16% wound complications, 5.8% malpositions of fixation, 1.2% thromboembolisms, 1.6% compartment syndromes, and 0.4% deep infections. All surgeons used the lateral extensile approach in their study.

According to a literature review done by Benirschke and Kramer5, serious infections (those requiring more than oral antibiotic therapy) after ORIF of closed calcaneus fractures range from 0% to 20%. They site three studies that claim 0% complication rates [11-13] and one study with a 20% complication rate. [14] The authors questioned the utility of these findings citing small sample sizes, short follow up times, multiple surgeons, and multiple approaches as concerns. To address those issues they reported on 341 closed calcaneal fractures treated by the senior author (Bernischke) with ORIF via an extensile lateral approach and a two layer closure. He reported only 1.8% of his subjects required further intervention. These finding were comparable to the largest study in their literature review which reported three deep infections in 114 fractures for a rate of 2.6%. [15] Benirschke cited non-compliance as the primary factor of his complications although smoking and predisposing medical conditions also contributed. Other authors have also found smoking, diabetes, and open fractures all increase the risk of wound complication after surgical stabilization of calcaneus fractures. Cumulative risk factors increase the likelihood of wound complications, and consideration should be given to nonsurgical management. [16]

As previously concluded by Pietzrak and Eppley [7], platelets direct wound healing. They appear almost immediately at the site of soft tissue injury and create a local environment conducive to tissue generation by secretion of proteins from their alpha granules. Basic science supports the hypothesis of enhancing healing by the placement of a supraphysiologic concentration of autologous platelets at the site of soft tissue injury.

So far, PRP has been applied to the following areas of medicine: cardiopulmonary bypass, mandibular bone augmentation for dental implants, diabetic foot ulcers, periodontal, lumbar spine fusion, and cutaneous ulcers, bone grafting, and cardiovascular surgery with documented success. [17-24]

Wound complications are the most common and potentially threatening consequence of ORIF of calcaneal fractures. There have been previous papers describing techniques to help lower this complication. Our series matched that of previous studies without a single wound complication. While our series is limited to 14 fractures, several important points can be made. Most series of high energy injuries refer to several factors that can influence complication rates: energy of the injury, surgeon experience, soft tissue handling, medical history, patient compliance, social habits, and nutritional status. It can be said with some certainty that constant experience with calcaneal fractures leads to a decreased complication rate. Although the purpose of this case study is to offer the addition of PRP and PPP to the treatment of these complicated injuries, we believe that our low complication rate is multifactorial. This includes pre-operative bulky Jones type splinting, appropriate surgical timing, pre-operative intravenous antibiotic administration, extensile lateral subperiosteal approach, “hands off” retraction, low profile hardware, drain placement, layered closure with Algower-Donati suture technique, surgeon experience and appropriate post-operative bulky splinting.

References

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Address correspondence to: Travis Motley, DPM, MS, FACFAS, John Peter Smith Hospital, 1500 South Main Street, Department of Orthopaedics, Fort Worth, TX 76104. tmotley@jpshealth.com

Travis Motley, DPM, MS, FACFAS, John Peter Smith Hospital, 1500 South Main Street, Department of Orthopaedics, Fort Worth, TX 76104. tmotley@jpshealth.com
J. R. Clements, DPM, FACFAS, The Carilion Clinic,Department of Orthopaedics, Three Riverside Place, Roanoke, VA 24014. jrclements@carilion.com
J. Kalieb Pourciau, DPM, Acadian Medical Center, 3521 Hwy 190 East, Suite U, Eunice, LA 70535. kpourciau@gmail.com

© The Foot and Ankle Online Journal, 2009