Treatment of intraarticular calcaneal fractures in adults. A treatment algorithm

Abstract

Significant progress has been made in terms of the management of calcaneal fractures. This is reflected in the marked decrease in complication rates associated with the current intervention of these potentially devastating injuries. The treatment priorities that, in the authors opinion, are key to achieve best results in a displaced calcaneal fracture are anatomic reconstruction of the entire calcaneus: articular surfaces, height, alignment, and length, with a function directed postoperative management. The value of these priorities are confirmed by the authors longterm follow-up results as presented here. To reemphasize, conservative treatment should be considered only in cases of extraarticular fractures, minor displaced intraarticular fractures in nonambulatory patients, and in cases where there is a clear contraindication for surgery. Regarding the technical requirements for an anatomic reconstruction, the os calcis fracture should be categorized as a procedure for experts. In two-part fractures, according to the Sanders classification, an anatomical reduction is obtainable in more than 80%-90% of cases. However, in consideration of the articular cartilage damage, a 70% rate of good to excellent clinical results seems realistic. In three-part fractures, anatomic reduction is attainable in about 60% of cases with a 70% rate of good results. These two subgroups comprise about 90% of all calcaneus fractures. It is the authors recent experience to optimize the extended lateral approach using posteromedial and anterolateral windows, so that an anatomic reduction in more than 60% of Sanders Type III os calcis fractures can be achieved. Further scientific work in this area of trauma orthopedics would benefit most from a general consensus on a fracture classification system and on a clinical scoring system, with 5 year follow-up studies using these treatment methods and evaluation systems.