Eur J Orthop Surg Traumatol (2005) 15: 122–128 DOI 10.1007/s00590-005-0223-0

O R I GI N A L A R T IC L E

Vasilios D. Polyzois Æ Thomas J. Zgonis Theodoros B. Grivas Æ Spyridon J. Plessas Vasilios D. Nicolaidis Æ Dimitrios S. Korres

A modified technique for the treatment of intra-articular calcaneal fractures with the use of the Ilizarov apparatus Received: 8 May 2004 / Accepted: 7 December 2004 / Published online: 2 March 2005 Ó Springer-Verlag 2005

Abstract The management of intra-articular calcaneal fractures during the past years has been ranged from the nihilistic approach of no active treatment to open reduction and internal fixation (ORIF) or even to early subtalar arthrodesis. The management of such fractures with the use of circular external fixators in a closed fashion or in combination with minimal approach is demonstrated in our study. The midterm results of 36 intra-articular calcaneal fractures treated between 1996 and 2003 with the use of the Ilizarov apparatus according to our modified operative strategy are presented. In treating calcaneal fractures, the classic EssexLopresti classification into depression and tongue type has been proved very useful in our hands. While the depression-type fractures can be reduced through skeletal traction and the above-mentioned minimal approach, tongue-type fractures can cause difficulties in reducing and especially maintaining the reduction of the The authors have not received and will not receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. V. D. Polyzois (&) Æ T. B. Grivas Department of Orthopaedics and Traumatology, Thriasio General Hospital, Gennimata Ave., 19200 Magula, Athens, Greece E-mail: [email protected] Tel.: +30-694-4353135 Fax: +30-210-7649505

tongue fragment. Especially for these fractures, a combined technique was applied by reducing the fracture with Steinmann pins according to the Essex-Lopresti method and incorporating them into the Ilizarov apparatus. This technique appears to be a lot easier and more accurate than the alternative ‘‘bent-wire technique’’ for reducing and holding down a tongue fragment. The original Essex-Lopresti manipulation alone with plaster immobilization does not allow weight bearing and is associated with regional osteoporosis. Apart from the Essex-Lopresti classification, the material was also categorized by the widely accepted Sanders CT classification for comparison of our results to those of the literature. The SF-36 patient-oriented general health status questionnaire was utilized before, during, and after the treatment period to assess patients’ satisfaction levels. We propose this operative strategy as an option for the treatment of all calcaneal fractures. Keywords Calcaneal fractures Æ Essex-Lopresti manipulation Æ Ilizarov apparatus Æ Intra-articular fractures Æ Tongue-type fractures Traitement des fractures intra-articulaires du calcane´us par le fixateur externe d’Ilizarov

V. D. Nicolaidis Fourth Department of Orthopaedics and Traumatology, KAT Hospital, Athens, Greece

Re´sume´ Le traitement des fractures articulaires du calcane´us fait appel au traitement fonctionnel, a` la re´duction oste´osynthe`se a` foyer ouvert, voire a` l’arthrode`se sous-talienne primitive. Les auteurs rapportent une se´rie de 36 fractures traite´es par fixateur d’Ilizarov entre 1996 et 2003. Fonde´e sur la classification d’Essex Lopresti, ils pre´cisent leur technique dans les fractures thalamo-tube´rositaires et dans les fractures enfoncement. Ils e´tudient le degre´ de satisfaction du patient par rapport au traitement choisi graˆce au questionnaire SF 36, utilise´ avant, pendant et apre`s l’application du fixateur.

D. S. Korres First Department of Orthopaedics and Traumatology, KAT Hospital, University of Athens, Athens, Greece

Mots cle´s Fracture du calcane´us Æ Fixateur externe Æ Fracture articulaire

T. J. Zgonis Center for Reconstructive Foot Surgery, Plainville, CT, USA S. J. Plessas Second Department of Orthopaedics and Traumatology, A. Olga Hospital, University of Athens, Athens, Greece

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Introduction Calcaneal fractures are often disabling injuries, especially when there is intra-articular involvement, and they should be treated like any other fractures of major weight-bearing joints [22]. In the adult population calcaneal fractures account for approximately 60% of all foot fractures and up to 2% of all skeletal fractures. Up to 70–75% of calcaneal fractures are intra-articular with the remaining 25–30% extra-articular [23]. As early as 1908 Cotton and Wilson suggested that open reduction of some calcaneal fractures was contraindicated [7]. McLaughlin agreed, likening attempts of operative management to the ‘‘nailing of a custard pie to the wall’’ [14]. In adults the calcaneal fracture is most commonly caused by a fall from a height or a motor vehicle accident, which deliver axial loading to the calcaneus and often results in compression and displacement of the fracture fragments [15]. The most commonly involved area is the posterior facet of the subtalar joint. The generally accepted treatment for displaced intra-articular calcaneal fractures is open reduction and internal fixation [11, 12, 16, 18, 19, 22]. Treatment with open reduction and internal fixation (ORIF) may be contraindicated when severe comminution and soft tissue disruption are present. The ORIF technique has also certain disadvantages such as being a technically demanding procedure and having a limited ability to anatomically restore alignment of the subtalar joint and the shape of the calcaneus [23]. Another problem is that the patient is generally kept non-weight bearing for a minimum of 6–8 weeks, and this results in severe regional osteoporosis [22]. On the other hand, closed reduction does not address anatomical restoration and often results in significant residual pain and functional limitations [15]. The authors propose the use of the Ilizarov device for treatment of intra-articular calcaneal fractures as a means of reducing and manipulating fracture fragments with tensioned wires in a closed fashion. The use of the Ilizarov method must not abate the aim for restoration of width, length, and height of the calcaneus along with anatomic realignment of the posterior facet. Fractures are stabilized by mounting the wires and tensioning on the Ilizarov rings. A minimal

Fig. 1 Lateral X-ray and CT tomography in axial and coronal plane of a joint depression type, Sanders type III calcaneal fracture

incision for reduction of a seriously displaced posterior facet can be performed if considered necessary. As far as tongue-type fractures are concerned, the shape of the calcaneus can be easily restored with the traditional Essex-Lopresti technique under fluoroscopy [9]. Instead of applying plaster of Paris, we incorporate the pins used for reduction of the fracture fragments on the Ilizarov device. We propose weight bearing for all types of fractures as soon as possible, even starting from the first postoperative day.

Material and methods From 1996 to 2003, 34 patients (28 men, six women), aged 22–68 (average 43.8) years with 36 calcaneal fractures were treated according to our operative strategy. Two patients had bilateral fractures. Twenty-four fractures (66.7%) resulted from a fall from a height, eight (22.2%) from a motor vehicle accident, and four (11.1%) from indirect trauma. Right after patient’s admission, projections in plain radiographs that included anteroposterior (AP), oblique, and lateral views of the foot and a Harris axial view, were performed. These four views often provide adequate definition of the fracture anatomy [20]. Even if it is considered that they do, the use of computer tomography (CT) in both axial and coronal planes is part of the protocol for safe documentation of the fracture pattern (Fig. 1) [6, 8, 19]. The fractures were classified as follows: nine tongue type (25%) and 27 depression type (75%). According to the Sanders CT classification system, 12 were type II (33.3%), 22 type III (61.2%), and two type IV (5.5%). No Sanders type I fracture was identified. All tonguetype fractures were Sanders type II. Three joint depression fractures were categorized as type II. All Sanders type III and IV were joint depression type according to the Essex-Lopresti theory [9, 20]. In summary, we treated nine tongue type, Sanders type II fractures (25%), three joint depression type, Sanders type II (8.3%), 22 joint depression type, Sanders type III (61.2%), and two joint depression type, Sanders type IV (5.5%) (Table 1). In the event that surgery was delayed due to the medical condition of the patient, elevation of the limb, a Jones compressive dressing, and a posterior splint were

124 Table 1 Categorization of the material by the Essex-Lopresti (E-L) classification system, by the Sanders system, and by the combined E-L and Sanders CT system Fracture classification E-L

Sanders CT

Combined E-L and Sanders CT

9 E-L tongue type 27 E-L joint depression type

12 Sanders type II fractures 22 Sanders type III fractures 2 Sanders type IV fractures

9 tongue type, Sanders type II 3 joint depression type, Sanders type II 22 joint depression type, Sanders type III 2 joint depression type, Sanders type IV

utilized to help control edema [19]. As soon as the patient became stable, surgery was performed, regardless of the amount of swelling. The Ilizarov fixator was applied to all patients. In 24 cases, we combined the Ilizarov technique with open reduction through a lateral minimal approach. Mean fixator duration was 6.8 (range 6–9) weeks. The longest follow-up to date was 7 years with a mean of 2.5 years. All patients completed the SF-36 patient-oriented general health status questionnaire prior to their Ilizarov reconstruction while in the Ilizarov frame and postoperatively [13]. For depressed-type fractures, the first step of the operating technique consists of application of a reductive force through traction with simultaneous manual compression on both sides of the calcaneus [9, 16, 20]. A 1.8-mm smooth wire is driven transversely through the

Fig. 2 Application of skeletal traction using 15–20 kg

Fig. 3 Elevation and reduction of depressed fragments, under fluoroscopy, with the use of a small periosteal elevator

posterior aspect of the calcaneus to which is applied skeletal traction using 15–20 kg (Fig. 2). Placement of this wire should not interfere with the ability to later place wires on either side of the calcaneus. The reductive force through traction should be directed posteriorly and distally. The aim with traction is to reestablish, as anatomically as possible, the length and height of the calcaneus. In so doing, deviations of Bohler’s angle (normal 25–40°) and the critical angle of Gissane (normal 125–140°) are also addressed [3, 4, 26]. The aim with manual compression is restoration of the width of the calcaneus and correction of any valgus or varus of the tuberosity. Following adequate reduction, fluoroscopic projections are obtained, mainly for visualization of the posterior facet. The best projection with fluoroscope for assessment of the posterior facet reduction is the Brodens’ view [5]. In most joint depression fractures, a satisfactory reduction of the joint surface is unachievable by this closed fashion reduction solely, so a small right-angled lateral incision is made inferior to the lateral malleolus. This approach minimizes the sequelae of peroneal tendinitis and devascularization of the anterior skin flap and preserves the sural nerve [17, 18, 19]. The depressed fragment of the posterior facet is identified fluoroscopically. After gently pulling the lateral cortex out of the way, any depressed fragment is reduced to its normal position using a small periosteum elevator (Fig. 3) [2, 15, 16, 23]. A smooth wire is inserted from medial to lateral, to maintain reduction. Right when its free end exits the elevated fragment, the lateral wall is repositioned, and the wire is further driven through it to transfix all fragments together. Another wire is inserted from medial to lateral with the aim of stabilizing the

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Fig. 4 Step-by-step construction of the Ilizarov apparatus

anterolateral fragment. The defect beneath the elevated fragment is sometimes filled with a bone graft to minimize the possibility of calcaneal deviation to varus [19]. Frame application is performed by the original Ilizarov technique. The frame is constructed step by step as soon as the rest of the wires are in place (Fig. 4). A coronal plane 1.8-mm wire, without olive, is placed into the tibia at the level of the proximal ring. Three additional 1.8-mm tibial wires, without olive, are added to make pairs of wires per ring. Two additional 1.8 mm wires, with olive, are introduced from the posterior portion of the calcaneus, exiting through the midfoot in a crosswise fashion. They support the reduction of the fracture fragments, which is mainly maintained by the first two wires. They also help in keeping the foot perpendicular in relation to the tibia once fixed to the footplate (Fig. 5). The tibial rings are then attached in a slightly off-center position approximately two finger widths from the tibia anteriorly (Fig. 6). All tibial wires are fixed to the rings and tensioned to 110 kg. All foot wires are fixed to the footplate and tensioned to 90 kg. Distraction of the subtalar joint is then carried out by increasing the distance between the footplate and the most distal tibial ring. This is achieved by loosening the nuts on the dorsal side of the ring and tightening the

Fig. 5 Careful attachment of wires and assembly of the apparatus in order to maintain the foot perpendicular to the tibia

Fig. 6 Slight off-center position of the apparatus in relation to the tibia

nuts on its plantar side. Fluoroscopic evaluation of the final fracture reduction is then performed and, if satisfactory, skeletal traction is then removed from the extremity. For tongue-type fractures, the combination of the Essex-Lopresti and Ilizarov techniques can be easily performed (Fig. 7a, b). If the pins that restore the shape of the calcaneus are facing downward after reduction, we introduce other pins in a parallel fashion to the horizontal level, even facing upward, paying attention to reduction preservation (Fig. 7c–e). This change should be performed because if a pin is facing downward, it can cause an obstacle for ambulation. In our hands the alternative of introducing transverse wires after achieving reduction resulted in loss of fracture reduction, sometimes marked. On the other hand, the other popular alternative for dragging and holding down the tongue fragment by the ‘‘bent-wire technique’’ can never provide accurate reduction. In our series, it was decided not to perform primary arthrodesis of the subtalar joint in the two Sanders type IV cases, in contrast to what many reports in the literature advocate [19, 20]. In all cases ambulation to tolerance is advised, even from the first postoperative day.

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Fig. 7 a Tongue type, Sanders type II calcaneal fracture. b–c Reduction by the Essex-Lopresti manipulation under fluoroscopy.

On average, the frame stays in place for 6–8 weeks. Once it is removed, the patient is partially weight bearing for another week. In cases with bilateral fractures, we suggest the use of a walker during this period. After an average of 7–9 weeks, the patient is allowed to bear weight unprotected and begins physical therapy to improve ankle and subtalar range of motion.

Results Treatment time ranged from 6 to 9 weeks, with a mean of 6.8 weeks. All patients underwent subjective and objective clinical evaluation using the Maryland Foot Score, according to which results were categorized as excellent (90–100), good (75–89), fair (50–74), and poor (50) [15]. Eight of the 36 intra-articular fractures (22.3%) rated as excellent. Seven of these were tongue type, Sanders II, and one was a joint depression type, Sanders type II. In these patients subtalar range of motion was greater than 50%, and they experienced mild pain diminishing with time and tolerable. Twenty of the 36 fractures (55.5%) rated as good. Two of them were tongue type, Sanders type II, another two were joint depression type, Sanders type II, and 16 were joint depression type, Sanders type III. Subtalar joint range of motion was also greater than 50%, but they had more severe pain not diminishing with time but still tolerable. Six out of 36 fractures (16.7%) were rated as fair due to a less than 50% range of motion of the subtalar joint and chronic pain, especially with prolonged ambulation. Five of them were joint depression type, Sanders type

III, and one was joint depression type, Sanders type IV. Two of the 36 fractures (5.5%) rated as poor. One of these fractures was classified as joint depression type, Sanders type IV while the other one was a joint depression type, Sanders type III (IIIBC) (Table 2). After thorough examination and guided by the fact that these two patients showed pain in both extremities, CT and MRI scans of the thoracic and lumbar spine were performed as well as nerve conduction studies. These revealed an L4–L5-level central compression in one case and an L5–S1-level central compression in the other case, respectively, due to disc ruptures that probably related to the episode of falling from a height because there was no MRI evidence of degenerative disease of the spine. Both patients were treated conservatively for their spinal injury, which resulted in subsidence of their foot and leg pain to tolerable levels. Significant relationship between the combined classification and clinical outcome was noticed (SPSS v11.01 Pearson correlation r=0.732, significant at the 0.01 level). No patient experienced any failure of hardware. Limited intolerance of the fixator was observed in two patients: the ones with bilateral fractures for the first few Table 2 Evaluation of results using the Maryland Foot Score Results Fracture classification

Maryland Foot score

7 tongue type, Sanders type II 1 joint depression type, Sanders type II 2 tongue type, Sanders type II 2 joint depression type, Sanders type II 16 joint depression type, Sanders type III 5 joint depression type, Sanders type III 1 joint depression type, Sanders type IV 1 joint depression type, Sanders type III 1 joint depression type, Sanders type IV

Excellent Excellent Good Good Good Fair Fair Poor Poor

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days. All patients were able to at least partial weight bear during the treatment period, and no one needed any kind of assistance for full weight bearing after 10 weeks. Five patients developed a superficial skin infection at a wire insertion site. None required the removal of a wire. No patient had evidence of fibulocalcaneal impingement or increased heel width. None had plantar heel pain. To date, none of the patients has required further surgical intervention. No patient had to make shoe modifications, and all were able to perform daily activities. All but one returned into their previous activities. The severity of disability experienced by these patients was illustrated by low preoperative SF-36 scores. Scores remained poor during the ‘‘in-frame’’ period, but remarkable increases were seen in postoperative values. The Wilcoxon test was used, and significant improvements between preoperative and postoperative SF-36 values were seen in general health perceptions (from average 36.1 to average 55.5, p=0.02), pain index (from average 36.6 to average 61.2, p=0.008), and emotional role function (from average 38.7 to average 74.2, p=0.01). No significant improvements, as expected, were noticed in mental health (from average 63.2 to average 69.6, p=0.221).

Discussion Distinct advances have been made in the treatment of intra-articular calcaneal fractures [1, 8, 19, 25]. They require anatomic reduction and stable fixation in order to improve the chances of a good outcome. The goal of any treatment is to restore not only articular congruency but also the shape and alignment of the calcaneus. Open reduction and internal fixation through lateral approach, with or without the use of bone graft, is still the gold standard in the treatment of displaced intra-articular calcaneal fractures [19, 20, 22]. Traditional open operative treatment should be delayed until swelling has subsided. One of the principles of internal fixation is early range of motion; however, in regard to fractures of the calcaneus, early range of motion does not mean early weight bearing. It has been observed that non-weight bearing with early range of motion does not necessarily ensure good outcome and may in fact result in significant residual pain, especially in the plantar heel [15]. The benefits of early weight bearing, as demonstrated by Paley and Fischgrund in six of seven patients who underwent anatomic restoration of the subtalar joint and heel with circular external fixation, can help to ensure an improved outcome. They showed that through early weight bearing, the plantar-heel fat pad was desensitized and thus helped to prevent chronic heel-pad pain and dystrophy [15]. The Ilizarov method of using external ring fixation in the treatment of calcaneal fractures applies the basic principles and techniques of closed fracture reduction and stabilization through the use of tensioned wires

attached to the frame. For tongue-type fractures, the accuracy of closed reduction by Essex-Lopresti manipulation meets the benefits of early weight bearing by applying the Ilizarov apparatus instead of a plaster cast. For fractures with displacement and depression of the posterior facet of the subtalar joint, the use of the Ilizarov apparatus is better combined with minimally invasive open reduction because restoration of the articular anatomy of the subtalar joint is very difficult to achieve in a completely closed fashion. At the same time the Ilizarov frame permits distraction of the subtalar joint. This may help to prevent soft tissue contracture during the period of immobilization, which could help to avoid postoperative joint stiffness. In addition, distraction eliminates the weight bearing forces across the subtalar joint, which can result in joint degeneration. Consequently, cartilage repair and regeneration may be stimulated at the posterior facet articulation, thus delaying the onset of subtalar joint arthrosis [10, 17, 21, 24].

Conclusion The above-mentioned strategy offers the unique advantage of immediate intervention in all situations, even in cases with a high degree of comminution and soft tissue disruption. It also introduces a way to reduce and fix tongue-type fragments easily, a problem that is not addressed from the authors who use ring external fixators for the treatment of calcaneal fractures. We suggest our operative strategy as a viable alternative for treatment of all intra-articular fractures of the calcaneus and as a method of choice for all surgeons experienced with Ilizarov operative principles.

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