Calcaneal fractures: indirect reduction and external fixation

The current treatment of displaced intra-articular calcaneal fractures has been surgical fixation. The objective of this study was to evaluate the use of indirect reduction with Ilizarov external fixation as a viable alternative in the surgical treatment of certain calcaneal fractures.

Thirty-one patients with 33 fractures of the calcaneus (Sanders types II, III, and IV) were treated using small wire circular external fixation. A limited percutaneous plantar skin incision was used to improve reduction of the posterior facet. Fractures were evaluated by preoperative CT scans and classified by an independent observer. Patients were evaluated by physical examination as well as by the AOFAS hindfoot score questionnaire. Followup ranged from 6 months to 4 years.

The average AOFAS score for 18 patients available for examination was 66 (42 to 92). The average score increased to 74 for patients with more than 10 months followup and to 77 for patients with isolated calcaneal fractures. Open fractures also had early debridement and soft-tissue coverage; no deep infections were seen in this subgroup. There were 11 complications, including nine superficial pin track infections, one superficial skin necrosis under an area of fracture blister, and one deep infection in a diabetic smoker with severe hemorrhagic fracture blisters. All superficial infections responded to local pin or wound care and oral antibiotics. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done. All open fractures healed and maintained soft-tissue coverage.

Indirect reduction and external fixation is a viable surgical alternative for intra-articular calcaneal fractures. Particularly favorable results were obtained in open fractures when soft-tissue reconstruction also was done. Advantages include shorter time to surgery, immediate weightbearing, minimal invasiveness, few serious wound problems, and no residual hardware. Disadvantages include technical difficulty, incomplete reduction of fracture fragments, and the need for secondary surgery (fixator removal).