To The Editor:
We congratulate Dr. Sanders on his excellent Current Concepts
Review "Displaced Intra-Articular Fractures of the Calcaneus" (82-A:
225-50, Feb. 2000). Since this topic is of paramount interest and
is still a matter of some debate, we would like to provide some information
from the non-English-language literature.
The historical review should mention the pioneering work of the
French school in the 1920s, above all Leriche, who, dissatisfied
with the results of closed treatment of calcaneal fractures, practiced
open reduction and internal fixation with staples and screws1. The method of percutaneous leverage of
the displaced tuberosity fragment and subsequent plaster immobilization of
the pin was introduced as early as 1934 by the German surgeon Westhues2. We are well aware that the difficulties in
the management of calcaneal fractures are reflected by a long historical record
of different treatment options. However, the two above-mentioned procedures
represent "milestones" that influenced and inspired
surgeons like Palmer and Essex-Lopresti, who established the principles
of modern treatment of calcaneal fractures.
The computed-tomography-based classification by Zwipp and colleagues3, which was cited by Dr. Sanders,
has proved to be of prognostic value when supplemented by an evaluation
of soft-tissue damage and comminution on a 12-point scale. Bone
fragments (maximum, five) and affected joint facets (maximum, three)
are credited with 1 point each. Open or closed soft-tissue damage
is scored on a 3-point scale. An additional point is assigned in
case of extensive comminution of one major bone fragment or a fracture
of another tarsal bone. With a predictive value of 86%,
an excellent result can be expected with less than 7 points; a good result,
with 7 or 8 points; a satisfactory result, with 9 to 10 points;
and a poor result, with 11 or 12 points4.
These results were confirmed in a preliminary series of seventy-nine
patients in our current study in Dresden5.
We wholeheartedly agree with Dr. Sanders’ conclusion
that restoring the shape of the calcaneus and achieving joint congruency
are the major goals of open reduction and internal fixation of calcaneal
fractures. He recommends the use of intraoperative Brodén
radiographs to ensure anatomical reduction. In our experience, minor
step-offs of 1 to 2 mm in the articular surface, which lead to a
significant load redistribution in the posterior facet of the subtalar joint6, cannot be detected with fluoroscopy. We
therefore perform intraoperative subtalar arthroscopy with a small-diameter
arthroscope to accurately assess the reduction of the saddle-shaped
joint surface before application of the calcaneal plate. So far,
this has proved to be a quick and reliable procedure to ensure anatomical
reduction of the posterior facet7.
To The Editor:
Congratulations to Dr. Sanders for his most thorough Current
Concepts Review, "Displaced Intra-Articular Fractures of
the Calcaneus" (82-A: 225-50, Feb. 2000).
Today, most calcaneal fractures are treated by the lateral approach
that he described. No alternative methods are suggested in this
review.
The author has listed several serious complications associated
with this technique. There are other reports describing serious
complications following lateral open reduction8,9.
Skin closure may be difficult or impossible. Wound breakdown may occur,
requiring local or distal skin flaps. Chronic infection may lead
to prolonged morbidity and even to excision of the calcaneus3 or to amputation10.
In choosing a method of treatment for displaced calcaneal fractures,
the surgeon must be aware of the risks involved for each of the
various methods considered. There can be significant risk with use
of the lateral approach for some patients, such as smokers and those
with diabetes or vascular disease. I have advocated a medial approach,
which has avoided these complications11-14.
Dr. Sanders cites my latest publication14 and
reports the good results and minimal complications; however, he
considers it a principal disadvantage that additional lateral incisions
were required. My data cannot be used for purposes of comparison
in Dr. Sanders’ review, because computed tomographic scans
were not used for evaluation of the severity of the fractures.
In the Conclusions section, Dr. Sanders strongly recommends the
use of intraoperative fluoroscopy for Brodén, lateral,
and axial radiographs to ensure an anatomical reduction. If Brodén
radiographs are valuable in surgery, I believe that they are valuable
for preoperative evaluation also. The classification of fractures
on the basis of Brodén radiographs is an excellent tool
for determining the severity of the fracture. I believe that the
results of the medial approach14 can
be favorably compared with those of the lateral approach, although
computed tomographic scans were not made for classification in my
study.
I do not feel that the small lateral incisions are a disadvantage.
They enable one to make a direct reduction of the posterior facet
fragments. The difficulty in reduction of the posterior facet fragments
from the medial side has always been a criticism of the technique.
Over the last four years, in our hands, few lateral incisions have
been necessary because the reduction of the depressed fragments
of the posterior facet has been guided by image intensification.
I have come to believe that anatomical reduction of the posterior
facet is not necessary to achieve good results. Parmar et al.15 came to this same conclusion; they suggested
that the posterior facet is not as important as is generally accepted. They
stated that the disabling pain after fracture clearly does not arise
from secondary arthritis. Lindsay and Dewar16 were
very positive that few symptoms arise from the damaged subastragalar joint.
Paley and Hall17 stated that there
is a relationship between anatomic abnormalities of the heel and
a poor clinical outcome. While the abnormalities include those of
the subtalar joint, it is insufficient to focus on that joint alone.
One should make an attempt to reduce the posterior facet anatomically,
but patients in my series have had good results without a perfect reduction
of this facet. There can be good results with nonoperative treatment
of comminuted displaced fractures. It is very important, however,
to restore the anatomy of the calcaneus.
If the posterior facet cannot be reduced adequately with use
of the medial approach but the anatomy of the calcaneus has been
so restored, I suggest that nothing more be done to attempt reduction
of the posterior facet. The patient may do well. If the patient
has pain following surgery, then a subastragalar fusion can be done
with good results. The patient will be much better off without a
serious complication following lateral reduction, such as leg amputation.
I recommend that orthopaedic surgeons treating calcaneal fractures
with open reduction review this technique14.
I believe that if they try the medial approach, its many advantages
will be apparent and their results will be good, as mine have been.
This is a safe alternative to the lateral approach for the reduction
of calcaneal fractures.
R. Sanders replies:
I have read the two letters sent to The Journal regarding
my Current Concepts Review on calcaneal fractures. I am in agreement
with most of the comments. Certainly, the comments of Drs. Rammelt,
Gavlik, and Zwipp, suggesting the historical importance of the surgical treatment
innovations of Leriche and Westhues, cannot be minimized. Furthermore,
I agree that the classification by Zwipp et al. is useful; however,
it may be a bit too cumbersome for most surgeons. Indeed, my own
classification system has been condensed by most practicing orthopaedists
into parts (I-IV), with omission of the level of the fracture line
(A-C), because it seems too cumbersome for daily use. In regard to
the use of intraoperative Brodén radiographs, if the foot
is rotated and flexed under fluoroscopy, one can see even the most
subtle articular step-offs, especially with fourth-generation fluoroscopes,
which are available in the United States today. There is nothing wrong
with arthroscopy, and I eagerly await the results of the ongoing
study mentioned by Drs. Rammelt, Gavlik, and Zwipp, for any method
that can improve a surgical outcome is a welcome addition to the
armamentarium.
Dr. Burdeaux has pioneered surgery of the calcaneus, and he was
doing so while I was still a resident in orthopaedics. His vast
knowledge and experience are unquestioned. After listening to his
lectures, reading his articles, and speaking to him personally,
I have tried over many years to perfect a medial reduction of the
articular surface. Unfortunately, I have failed, and hence my enthusiasm
for a lateral approach. While the calcaneal body can be restored
by the medial approach, I differ in philosophy regarding the maintenance
of malreduction of the posterior facet. Dr. Burdeaux suggests that
if a patient has subtalar arthritis as a result of this articular
malunion, a subtalar fusion may be performed with good results.
While this is true (fusions do work), why not give the patient the
best chance of a normal result by attempting an anatomic reduction
at the time of surgery? Perhaps because throughout my entire training
I have been taught to obtain an anatomic reduction of articular
surfaces, I must respectfully beg to differ with Dr. Burdeaux, and
that is why I embrace the lateral approach. Still, I would agree
that readers must formulate their own conclusions, both from the
published literature and from personal clinical experience.