Point-Counterpoint: Is External Fixation The Best Option For Calcaneal Fractures?

By Gary Peter Jolly, DPM, FACFAS, and Michael M. Cohen, DPM, FACFAS

Yes. This author emphasizes the use of external fixation and ligamentotaxis for treating calcaneal fractures, citing key benefits including earlier post-op weightbearing. By Gary Peter Jolly, DPM, FACFAS    Intraarticular calcaneal fractures have long been recognized as a devastating injury but, fortunately, they constitute only 2 percent of all fractures. While there is universal agreement on the severity of their impact, there has been anything but a consensus on how practitioners should manage these fractures.    The history of the treatment of calcaneal fractures has been a reflection of contemporary knowledge and techniques, including manual reduction, the Essex-Lopresti maneuver, pins and plaster, and simple immobilization in plaster. There has never been a “gold standard” because the outcome for almost every form of treatment has left much to be desired.    In the late 1980s, Hans Zwipp reported on an extended lateral incision and the use of plates and screws to treat intraarticular calcaneal fractures.1 Benirschke and Sangeorzan popularized the technique in this country and since then, a number of calcaneal plates have been developed to facilitate the reduction.2 Despite a better understanding of fracture mechanisms and the resulting lesion patterns, the reports of good outcomes are still not as consistent as we would like.3,4    Factors that negatively affect outcomes after the treatment of calcaneal fractures include arthritis of the subtalar joint, peroneal tendonopathy, difficulty with finding comfortable shoes, pain associated with the plantar heel pad and the development of markedly altered gait. Having said that, shouldn’t we consider alternative therapies that might offer improved outcomes?    If one were to poll the surgeons who deal with calcaneal fractures on a consistent basis, it would be my opinion that the vast majority, certainly those in the United States, would opt for open reduction and internal fixation. Then why do I suggest external fixation as a reasonable alternative to internal fixation? I have treated this most difficult fracture with both techniques and have had the opportunity to critically compare my own outcomes. I will share the reasons for my conversion from internal to external fixation and the epiphany that precipitated it.

Why Do We Use An Extended Lateral Incision?

   There are three universal goals in treating calcaneal fractures: restoring heel height; reducing heel width in order to decompress the peroneal tendons; and accurately reducing the articular surfaces. The real value of external fixation in treating calcaneal fractures is that it allows the surgeon to accomplish all three goals without jeopardizing the already compromised soft tissue envelope.    The extended lateral incision, which has been in use throughout the world since the mid-1990s, creates a full thickness flap of tissue over the lateral surface of the heel. This flap relies in large part on the presence of a patent lateral calcaneal artery to supply that flap with blood. When one contemplates open reduction and internal fixation for a calcaneal fracture, this calls into question the viability of this flap because compromise of this flap’s viability will lead to a significant slough and the exposure of metal and bone.    Furthermore, using an extended lateral incision, which strips the exposed bone fragments of the lateral nutrient arteries completely, devitalizes the lateral wall, the lateral articular fragment and the lateral half of the tuber. Bone without a blood supply is dead bone. Extensive stripping of the periosteum of any bone is discouraged for that very reason. Then why do we do it to the calcaneus?    The answer is simply to allow the application of hardware. In order for a calcaneal fracture to heal after it has been stripped and plated, one must revascularize the devitalized bone and replace it by creeping substitution. Wouldn’t it be better if we could realign the fracture fragments without having to disturb their soft tissue connections with each of the peripheral pieces of bone retaining their native blood supply? Of course it would and one can do this by a technique called ligamentotaxis.

How To Achieve Calcaneal Fracture Reduction Through Ligamentotaxis

   Ligamentotaxis is the phenomenon of fracture reduction by applying axial traction to a fractured bone when the soft tissue attachments of that bone are still intact. In ligamentotaxis, these attachments serve to draw the fragments back into anatomical alignment once one has restored the soft tissue component to its original length. If surgeons can reduce the nonarticular components of the fracture without direct visualization, then only the articular components will require operative intervention. A small, inframalleolar incision provides excellent exposure to the posterior facet. This incision enables one to reduce the articular component without jeopardizing the soft tissue envelope.    While I feel ligamentotaxis would be a better and safer method of treating a calcaneal fracture and actually achieving a quality reduction, some may wonder how they can perform this procedure. Talarico, et. al., described a technique for calcaneal fracture reduction and fixation in which one has the patient on a fracture table and places a traction pin through the calcaneal tuber.5 The surgeon would direct the vector of the traction in a plantar and slightly posterior direction, and do so under image intensification. As one exerts force on the tuberosity, the ligamentotaxis reduces the body of the calcaneus. Surgeons can assess any residual varus by obtaining an axial view of the calcaneus and, if necessary, one can adjust the position of the tuberosity manually.    After achieving a satisfactory position of the body of the bone, one can reduce the subtalar joint by making a horizontal incision directly over the joint and maintain it with a single 4.0 cannulated bone screw. Once the reduction is complete, apply a circular frame to the foot and leg while maintaining traction. After the frame is complete, disconnect the traction device. The static frame will maintain the reduction and is stable enough to allow the patient to bear partial weight on the foot as the fracture heals.    The external fixator provides two major effects. It maintains the traction on the tuber, which produced the reduction in the first place, maintaining it until the fracture has healed. The external fixator also provides stability to the fragments via judiciously placed smooth and olive wires so the final construct is stable. It is not voodoo. It is not smoke and mirrors. It is just an alternate way of maintaining an accurate anatomic reduction. For those of us who are old enough to remember the “pins and plaster” techniques for reducing long bone fractures, we cannot help seeing the similarity. Employing external fixation for the treatment of calcaneal fractures is really just applying an old method with modern equipment.

Does Ligamentotaxis Facilitate Earlier Post-Op Weightbearing?

   It should be noted that the outcomes Talarico, et. al. reported for treating fractures with external fixation and ligamentotaxis were quite good.5 Out of the 25 fractures treated, 32 percent were considered excellent and 60 percent were good, yielding a 92 percent rate of satisfaction. This is currently the only peer-reviewed paper on this technique so it would be easy to ignore it and rely instead on the weight of evidence that has been published on the extended lateral release and internal fixation. Certainly, the standard of care for the operative treatment of calcaneal fractures would seem to be this most invasive of techniques. Yet one cannot help but wonder if this less invasive and seemingly simpler method of treatment utilizing external fixation and skeletal traction might not be a better way to treat these potentially disabling injuries.    There is an additional benefit to external fixation for calcaneal fractures. While this benefit may not be crucial, it is worthy of note. When patients with calcaneal fractures use a well designed external fixator, they may begin to bear weight on that foot as soon as they can do so comfortably. This is in sharp distinction to those patients whose calcaneal fractures are treated with internal fixation. Since patients may bear weight in their frames, one can deduce that the fixation construct is significantly more stable and secure than the construct provided by a bone plate and screws. Paley has suggested that the introduction of weightbearing during the period of calcaneal fracture healing may provide the additional benefit of preventing fibrosis of the plantar heel pad and accordingly reducing some of the pain often associated with these injuries.6    In regard to my own initial series of eight patients (nine fractures), who we treated for calcaneal fractures between April and September 2004, all patients achieved a satisfactory reduction of both the non-articular and the articular components. Five of the fractures occurred among males between the ages 33 and 41, and all of these individuals were able to return to work by the 14th postoperative week. All of these individuals worked in the building trades.    Although this debate centers on internal versus external fixation, it really should be a comparison of open reduction and internal fixation against traction and percutaneous rigid external fixation. Applying a static circular frame after achieving reduction by ligamentotaxis and a limited open reduction of the joint should be an extremely attractive alternative for the foot and ankle surgeon. After all, the first principle of treating patients is “Primum non nocerum.” Using an extended lateral incision and internal fixation would seem to violate this precept. While authors have reported good outcomes using this technique, Buckley, et. al., reported that patients who were treated nonoperatively obtained comparatively good results as well.4    Until now, functional results for both open reduction and closed treatment have not been exactly stellar. In measuring the success of any treatment of calcaneal fractures, there are several criteria which one should apply.    These criteria include the radiographic appearance of the height and width of the bone as well as the appearance of the subtalar joint, and the ability of the patient to resume his or her activities of daily living. If these criteria were weighted, clearly the latter would carry greater significance since the greatest endorsement that any treatment can receive is allowing the patient a return to his or her pre-injury level of activity.

In Conclusion

   Granted, we all strive to adopt an evidence-based approach to decision making in our own practice of foot and ankle surgery. It would also be very easy to look at the published data for each approach and, using nothing more than a scale, declare open reduction and internal fixation the winner by virtue of the sheer number of published papers on open reduction and internal fixation over the last 10 years.    However, the early data on limited open reduction, traction and the application of a static circular fixator shows genuine promise and should not be disregarded. Furthermore, one cannot disregard the fact that limited open reduction and the application of a rigid circular fixator is a far less invasive and a far more stable construct. This logically compels us to take a long, hard look at this technique as a strong candidate for the preferred treatment of calcaneal fractures. Dr. Jolly is a Fellow, Past President and Director of Fellowship Training of the American College of Foot and Ankle Surgeons. He is the Chief of Podiatric Surgery and the Director of the PGY IV Fellowship in Reconstructive Foot and Ankle Surgery at New Britain General Hospital in New Britain, Ct. Dr. Jolly is also a Clinical Professor of Surgery at the Des Moines University School of Podiatric Medicine and Surgery. Dr. Jolly’s e-mail address is gjolly8060@aol.com. References 1. Zwipp H, Tscherne H, Wulker N, Grote R. Intra-articular fractures of the calcaneus. Classification, assessment and surgical procedures. Unfallchirurg. 1989 Mar 92(3):117-29. 2. Benirschke SK, Sangeorzan BJ. Extensive intraarticular fractures of the foot. Surgical management of calcaneal fractures. Clin Orthop 1993 Jul; 128-34 3. Koval KJ, Sanders R. The radiologic evaluation of calcaneal fractures. Clin. Orthop Relat Res. 1993 May;(290):41-5. 4. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002 Oct;84-A(10):1733-44. 5. Talarico LM, Vito GM, Zyryanov SY. Management of displaced intraarticular calcaneal fractures by using external ring fixation, minimally invasive open reduction and early weightbearing. J Foot Ankle Surg. 2004 Jan-Feb:43(1):43-50. 6. Paley D, Fischgrund J. Open reduction and circular external fixation of intraarticular calcaneal fractures. Clin Orthop Relat Res. 1993 May;(290):125-31. For further reading, see “How To Evaluate And Treat Calcaneal Fractures” in the November 2005 issue or “Mastering Complications In External Fixation” in the August 2005 issue of Podiatry Today. Also be sure to check out the archives at www.podiatrytoday.com.    No. This author cites key limitations, a lack of evidence-based studies, a difficult learning curve and very few indications for external fixation in the treatment of calcaneal fractures. By Michael M. Cohen, DPM, FACFAS    As surgeons mature and gain experience, we develop the wisdom to never say never. Many of us have been around long enough to appreciate the fact that creativity is the mother of innovation and the use of external fixation for calcaneal fractures is no exception. At the same time, we must recognize that just because we have acquired a hammer, not every situation resembles a nail.    When discussing external fixation for these complex fractures, it is unfair simply to argue whether the technique is valid or not. After decades of debate, there is still no clear consensus regarding the indications for invasive reduction. This includes surgical methodology such as incisional approach and internal fixation devices, bone grafting and joint salvage versus arthrodesis. Those familiar with orthopedic history will attest to the cyclical arguments regarding the treatment of these fractures and only underscores the perpetual difficulty one encounters in treating them. In fact, evidence-based studies advocating the nonoperative approach continue to be published today.

Why There Are Flaws With Ex-Fix In Achieving Accurate Reduction

   That said, understanding the fracture pattern of the joint depressed calcaneal fracture is essential to execute a proper reduction. It is also necessary to understand the limits of external fixation.    There are generally four fragments in the post-morbid calcaneus, including the tuberosity (or tuber), the sustentaculum, the anterolateral fragment and the thalamic fragment. The goals of the surgery are to align the tuber (usually out of varus), decompress the flattened heel (to regain lost height) and reduce the lateral blowout (to relieve lateral impingement).    A very important goal is reducing the posterior facet anatomically, which includes the thalamic fragment. While surgeons agree that these fragments are, for the most part, amenable to indirect reduction through external manipulation and ligamentotaxis, this is not the case with the thalamic section (the depressed portions of the posterior facet). Accurate reduction of the facet generally requires a separate ancillary procedure. Even when one uses the standard closed reduction technique advocated by Omoto, authors concede that the method is ineffective in reducing multiple fractures of the facet.1,2    However, it is my opinion that one cannot accurately reduce a three- or four-part facet fracture by joysticking the fragments percutaneously with an elevator as one commonly sees with external fixation. A proper reduction requires direct visualization and the argument that the technique is noninvasive to the soft tissue structures is debatable.    Reducing the multiple facet fracture is also quite difficult with a fixator. This may require transverse olive wires (or screws) to prevent subchondral collapse while providing distraction of the tuber at the same time. Moreover, the bulky frame prevents one from manipulating the foot intraoperatively to obtain effective oblique Brodens type views. This often leads to a suboptimal reduction of the facet.    To emphasize this point, a recent study evaluated the accuracy of open reduction using the standard lateral extensile approach performed by experienced surgeons. After provisional fixation and seemingly anatomical realignment (confirmed intraoperatively with the use of standard Brodens and axial views), researchers unmasked a 1 to 2 mm step-off after arthroscopic reevaluation of the joint. Therefore, one must realize the shortcomings of percutaneous and limited reduction techniques of the facet.    Those debating the use of external fixation in the two-part fracture should recall that the Sanders CT classification is prognostic (p=0.06). Patients do quite well with open reduction internal fixation (ORIF) of this fracture and reportedly have a 71 percent good to excellent result while the facet was anatomically reduced in 86 percent of the patients. On the other hand, there are no published studies I am aware of that specifically delineate the outcome of each fracture pattern using external fixation in order to allow a fair comparison.

Addressing The Issue Of Immediate Weightbearing With Ex-Fix

   What other advantage could external fixation provide? Advocates of circular reduction boast that weightbearing induces “fat pad desensitization,” a phenomenon that patients could otherwise overcome with physical therapy modalities after standard open reduction.    Others cite the advantage of dynamization with immediate weightbearing. However, this advantage comes at the cost of eliminating immediate subtalar range of motion.    Keep in mind the historic problems that physicians have encountered with joint stiffness and pain after rigidly immobilizing intraarticular fractures for extended periods of time. Salter’s principles dictate that joint motion is necessary to help nourish and mold the damaged articular surfaces. While a frame may allow sagittal movement of the ankle by building collateral articulated struts, one cannot construct it to allow subtalar motion.    Regarding the argument that dynamization enhances bone healing, this may not be as important an issue for the calcaneus where the rate of nonunions is virtually nonexistent. Yet for obvious reasons, I do agree that weightbearing is clearly an advantage when one is faced with bilateral lower extremity trauma.

Underscoring The Lack Of Evidence And Difficult Learning Curve For Ex-Fix

   Still, proponents of external fixation advocate the method as a possible alternative to primary arthrodesis, stating that the technique is akin to distraction arthroplasty and results in improved symptoms because of the development of a joint cushion. However, these assumptions are just that and not a result of evidence-based findings. In fact, literature advocating external fixation for the calcaneal fracture is quite scant with very small patient pools, many of which have not appeared to be held to the same level of scrutiny as the multitude of articles published using other techniques. This may seem surprising since circular wire fixation of this fracture is not a new concept and dates back to 1993 when Paley introduced it to American orthopedic journals.3    Yet to be fair, it is possible that the technique has not received such enthusiastic support because of its steep learning curve. Today’s foot and ankle surgeons have a high degree of respect for the calcaneal fracture. It takes considerable time to adequately conceptualize the fracture pattern, which appears to present in so many variable ways. Sanders and Coughlin highlighted its complexity, noting that more experienced surgeons attained better outcomes when they performed open reduction of calcaneal fractures. One can just imagine the difficulty of raising the learning curve even higher by reducing the fracture with a circular frame.

Other Key Points To Consider When Comparing Internal Fixation And External Fixation

   Some point out that wound slough and deep infections are notable risks of open reduction and a cause for concern. Most reports point to the apex of the extensile incision, which is particularly at risk. Less recent articles have cited that soft tissue complications have the potential to become catastrophic.    While it is true that external fixation is less invasive to the soft tissue envelope, one must argue whether the incidence of complications is not exaggerated. Recently, Benirschke and Kramer reported an infection rate of 1.86 percent in 341 closed fractures and 7.7 percent in 39 open fractures.2 In their article, the authors underscored the need for meticulous dissection, proper incision placement, careful handling of the flap (using the “no touch technique”) and layered closure. Conversely, a recent article indicated a 30 percent complication rate using external fixation with the majority of complications being superficial and deep pin tract infections. Other articles also reported neuropraxia lasting many months.    It has been my experience that scrutinizing operative candidates closely will yield better outcomes regardless of the technique. Documented evidence reveals that medically compromised patients such as patients with diabetes, smokers and obese patients do not fare as well with surgery. Furthermore, careful attention to placing incisions away from devitalized areas will go a long way in preventing problems.    When comparing anesthesia risks, there is no question that external fixation requires a substantially longer operative time than ORIF, particularly when the surgeon is first becoming familiar with the technique. Secondly, the argument that ORIF requires a second operation to remove hardware is also invalid since a second operation is necessary to remove the fixator.    While I concede there is a place for external fixation of calcaneal fractures, the procedure is limited to the following few indications:    • high energy fractures resulting in significant soft tissue injury or open (grade III) fractures allowing staged procedures;    • severe comminution not amenable to plating or internal hardware;    • bilateral calcaneal fractures, which generally have a poorer prognosis regardless of treatment type (external fixation is convenient in these cases because it allows weightbearing in a patient who would otherwise be required to remain completely non-weightbearing for about three months); and    • medical problems precluding large incisions.    Clearly, these indications are rarely seen in an average practice and constitute a very small percentage of the fracture population.

In Conclusion

   Fracture specific hardware for the foot and ankle is evolving at a rapid pace. At this time, calcaneal locking plates are available in different patterns to allow a more rigid construct. The plates are amenable to cortical and subchondral lag fixation for the subtalar facet. One can combine the technique with cannulation if necessary.    The open technique has the added advantage of allowing proper reduction of the calcaneocuboid joint if it is violated. External fixation has been criticized for producing less than attractive postoperative radiographs. When one performs rigid fixation under direct visualization, a more precise reduction is possible with immediate range of motion.    Nevertheless, it will be quite some time before the literature amasses enough large and long-term prospective studies to allow a fair comparison between the two techniques, so that as our experience widens, the indications for each technique will narrow. Dr. Cohen is a Fellow of the American College of Foot and Ankle Surgeons. He is the Chief of the Podiatry Section/Surgical Services and the Director of Podiatric Residency at the Veterans Affairs Medical Center in Miami. References 1. Talarico LM, Vito GR, Zyryanov SY, Management of Displaced Intraarticular Calcaneal Fractures by External Ring Fixation, Minimally Invasive Open Reduction, and Early Weightbearing: Journal of Foot and Ankle Surgery, Vol 43/No 1, pp 43-50, Jan/Feb 2004. 2. Benirschke SK, Kramer PA: Wound healing complications in closed and open calcaneal fractures. J Orthoped Trauma 18:1-6, 2004. 3. Paley D, Fischgrund J. Open reduction and circular external fixation of intraarticular calcaneal fractures. Clin Orthop 290:120-131, 1993. Additional References 4. Gur E, Atesalp S, Aydogan N, Erier K; Treatment of complex Calcaneal Fractures with Boney Defects from Land Mine Blast Injuries, Foot and Ankle International/Vol 20, No1, pp 37-41, Jan 1999. 5. Sanders R, Fortin P, DiPasquale T: Operative Treatment in 120 displaced Calcaneal Fractures. Results using computed Tomography Scan Classification. Clin Orthop, 290:87-95; 1993. 6. McGarvey WC, Burris MW. Calcaneal Fractures: Indirect Reduction and External Fixation. Techniques in Foot and Ankle Surgery: 3(4); 258-268, 2004. 7. Omoto H, Nakamura K. Method of Manual Reduction of Displaced Intraarticular Fracture of the Calcaneus. Technique, Indications, and Limitations. Foot and Ankle Int 22:874-9, 2001. 8. Rammelt S, Gavlik JM, Barthel S, Zwipp H. The Value of Subtalar Arthroscopy in the Management of Intra-Articular Calcaneus Fractures; Foot and Ankle Intl Vol 23/10; pp906-916, 2002. 9. Cohen MM, Calcaneal Fractures; in McGlamry’s Comprehensive Textbook of Surgery. Edited by Banks AS, Volume 2, (3rd Edit) pp1819-1863, Chapter 57, 2001. For further reading, see “Exploring New Advances In Internal Fixation” in the May 2005 issue or “External Fixation: Is It The Answer For Diabetic Limb Salvage?” in the July 2004 issue of Podiatry Today. Also be sure to check out the archives at www.podiatrytoday.com.

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