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.

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