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Dr. Alastair Younger, M.D., MB ChB FRCSC
Head, BC's Foot and Ankle Clinic,
Providence Health Care,
And Clinical Associate Professor,
Division of Lower Limb Reconstruction and Oncology,
Department of Orthopaedics,
University of British Columbia,
Vancouver, BC In any other joint, bone or part of the body, a displaced intra-articular fracture with malalignment is considered a surgical problem. It would seem logical that restoration of heel height, prevention of nerve and tendon entrapment, restoration of the normal anatomy of the heel cord, restoration of the normal contour of the foot and contact characteristics, and preservation of the joints by anatomic reduction would result in a better outcome for these fractures.
Figure 1:
A displaced calcaneal fracture with a 10-centimeter open wound over the medial side. Note the position of the tuberosity with the insertion of the Achilles tendon. Upon starting practice, I had a chance to see these late results of nonsurgical treatment and found an anatomic reason for ongoing pain (except for the occasional patient with a regional pain syndrome): arthritic changes in the subtalar and calcaneo cuboid joints, impingement of tendons, anterior impingement of the ankle from loss of heel height, and pain from calluses from abnormal loading of the foot were common complaints. The late reconstruction is a tough operation with high complications (nonunion, malunion) and a long recovery time. This, combined with the prolonged disability between the injury and surgery, almost invariably lead to a reduction in job status. Successful early anatomic open reduction internal fixation avoids these complications.
 | Figure 2:
A similar injury two years after nonoperative treatment. The patient is disabled and cannot be fitted with shoe wear to compensate for the deficient heel. The Achilles tendon is dysfunctional causing anterior impingement in the ankle joint and ongoing pain. Two late reconstructive surgeries have restored some heel cord lever arm, but with minor gains in function and symptoms. | Dr. Richard E. Buckley's benchmark paper makes many of the previous papers on ORIF of the calcaneus irrelevant, and, like all good papers, raises more questions than gives answers1.
The early results of Dr. Buckley and colleagues' excellent study showed no difference in outcome of operative and nonoperative treatment of displaced intra-articular fractures of the calcaneus. This, to a certain extent, was adopted with little questioning by many orthopaedic surgeons in Canada as a reason to leave these fractures alone. However, if any fracture had been studied this well (distal radius, tibial plateau, tibial shaft) with outcome being the main goal, similar results would have been obtained. This is because patient report is often not tied to outcome in trauma. Patients on worker's compensation (accounting for 37% of patients) are very unreliable reporters of outcome, and a significant proportion of fractures occur as a result of work-related injuries. Worker's compensation boards (WCBs) define disability along concrete physical findings such as loss of range of motion, and in many cases resort to private investigators to determine outcome. SF 36 outcomes, the index outcome criteria of the Buckley study, were not designed for assessing WCB patients. Should all future patients, WCB and non-WCB, have to have poor outcomes from nonoperative treatment because of the inaccurate reporting of a few WCB patients?
 |  | Figures 3 a) and b):
The fracture shown in Figure 1 after open reduction, debridement, primary subtalar fusion and a free flap. Note the restoration of the normal contour of the medial border of the calcaneus and correct position of the heel cord insertion. The posterior facet of the subtalar joint seen on the plantar aspect of the calcaneus had to be removed at six months as it was dysvascular and infected. He walks independently 1 year after the surgery and has no further signs of infection. | Outside of the worker's compensation patients other issues exist: The media creates an expectation within trauma patients that an operation will repair them 'back to normal'. Perhaps this is why open reduction internal fixation of ankle fractures is the main source of litigation for all surgery around the ankle2. Drug abuse, poor education and other injuries outside the calcaneus create many confounding factors to the reporting of outcome.
Despite these seemingly insurmountable obstacles, Dr. Buckley and colleagues have shown a significant benefit to open reduction and internal fixation of displaced intra-articular calcaneal fractures.
We need to improve surgical outcomes by referring to high volume trauma and foot surgeons. We must allow such surgeons to determine how to repair these difficult fractures well, such that reliable outcomes for surgery can be obtained. The operation's big 'Achilles heel', wound necrosis, can be surmounted by developments in minimally invasive surgery, a better understanding of the local anatomy, and a better understanding of risk factors3. Worker's compensation patients should be offered the surgery as the only means of restoring function, and we need to find more reliable outcome measures for this subgroup.
References
- Buckley R., Tough S., McCormack R., Pate G., et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am, 2002. 84-A(10): p. 1733-44.
- Mckenzie, G. Avoiding Lawsuits in Foot and Ankle Care in Canadian Orthopaedic Foot and Ankle Society Annual Symposium. 2003. Vancouver, BC.
- Abidi N.A., Dhawan S., Gruen G.S., Vogt M.T., et al. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Foot Ankle Int, 1998. 19(12): p. 856-61.
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