**7. Treatment**

Management of calcaneus fractures varies based on many factors. Nonoperative treatment is often recommended in extra-articular fractures with fragment size <1 cm in addition to less than 2 mm of displacement with an intact Achilles tendon. Nonoperative management is also indicated for Sanders Type I intra-articular fractures. Nonoperative management will typically consist of splinting and non-weightbearing or toe-touch weight-bearing for 6–8 weeks with early range of motion of the ankle and hind foot to prevent stiffness [38, 39].

There is debate in the current literature on whether many calcaneus fractures are best managed with open reduction internal fixation (ORIF) or nonoperatively [10, 39–44]. ORIF has been shown to have greater rates of complications and repeat surgeries but with better outcomes regarding time to return to work and shoe fitting. ORIF was most beneficial in fracture patterns associated with fibular impingement, lateral comminution, and Böhler angles between 0o and 14o [40, 44]. Nonoperative management increases the risk of late subtalar fusion by 550–600% due to symptomatic subtalar arthritis [45, 46]. Additionally, without initial fixation and restoration of calcaneal height, the later subtalar fusion procedure increases in complexity due to the deformity created by the malunion of the calcaneus. The economic impact of treatment decisions must also be weighed. Concerning the impact on US healthcare payers, ORIF treatment costs almost \$5000 less compared to nonoperative management over 5 years [47].

Operative management typically consists of ORIF, although external fixation for treatment of the calcaneus is well described (as discussed later in this chapter). ORIF can be performed through a traditional extensile lateral approach or minimally invasive approaches (**Figure 9**). Operative treatment aims to restore heel height and width, correct varus, and realign the subtalar joint. Operative indications include displaced tongue-type fractures with >1 cm of displacement; Sanders Type II, III, and IV fractures with articular displacement >1 mm; anterior process fracture with >25% involvement of calcaneocuboid joint; and displaced sustentaculum fractures [48].

Historically, ORIF has utilized the extensile lateral approach. This approach allows for excellent visualization of the subtalar joint by creating a full-thickness superior flap. It allows for the placement of a perimeter plate with fixation into the peripheral (more dense) bone of the entire calcaneus. The sural nerve and peroneal tendons are at risk during the approach and should be preserved. Meticulous and gentle softtissue handling should be observed (the so-called "no touch technique") [49].

Due to the risk of complications with ORIF, less invasive surgical techniques, such as percutaneous pinning, limited-incision sinus tarsi technique, and arthroscopicassisted reduction and internal fixation, have been explored for fractures previously treated with the extensile lateral approach [50, 51]. While initially, the use of less invasive techniques had limited indications, these approaches have been shown to have equal clinical and radiographic outcomes to the extensile lateral approach with less wound-healing complications for all intra-articular calcaneal fractures [39, 51–53].

#### **Figure 9.**

*Extensile lateral approach (A) and sinus tarsi (B) approaches to the calcaneus. MTB = Metatarsal Base, LM = lateral malleolus.*

### *Calcaneus Fractures DOI: http://dx.doi.org/10.5772/intechopen.114132*

The sinus tarsi approach often utilizes a 2–4 cm incision over the sinus tarsi from 1 cm distal to the tip of the fibula toward the base of the fourth metatarsal. This approach provides direct visualization, reduction, and fixation of the posterior facet and calcaneocuboid joint while minimizing soft-tissue trauma [54]. This technique minimizes the risk of sural nerve injury and decreases surgical time and postoperative wound infections while enabling the surgeon visualization to restore the Böhler angle [51, 55–60]. The minimally invasive longitudinal approach (MILA) is an evolution of the sinus tarsi approach that takes the incision 1.5 cm distal to the lateral malleolus from the base of the fourth metatarsal to 1 cm anterior to the Achilles [54]. MILA has shown improved outcomes compared to the traditional sinus tarsi approach when using perimeter plates and compression screws [61], except in highly comminuted Sanders type IV fractures where the sinus tarsi approach was superior, most likely due to better visualization of the posterior facet [61].

Percutaneous fixation can be achieved with or without utilizing the limited sinus tarsi approach [53, 62, 63]. Percutaneous fixation can be performed using a variety of techniques to reduce fragments and maintain fixation with an external fixator or cannulated screws (**Figure 10**).

Arthroscopic-assisted reduction and internal fixation (ARIF) has shown excellent outcomes [64–66]. However, this technique may require increased setup, technical difficulty, and soft-tissue swelling, although disposable arthroscopy systems exist that may allow for similar visualization without the inconvenience of full arthroscopy setup [65]. When comparing less invasive techniques, there is no reported difference in radiographic restoration of Böhler's angle and clinical outcomes (AOFAS scores) [53].

#### **Figure 10.**

*Utilization of percutaneous pinning for the fixation of a tongue-type calcaneal fracture. (a) Displaced tonguetype calcaneal fracture. (b) Reduction of displaced tongue-type fracture using a Kirschner wire. (c) Partially threaded and fully threaded cannulated lag screw placement for fixation. (d) Harris view of cannulated screw placement. (e) Final operative radiographs. (f) Postoperative radiographs.*

One study found an increased risk of secondary subtalar arthrodesis when performing percutaneous fixation due to subtalar osteoarthritis [67]. Percutaneous fixation is particularly indicated for patients with peripheral vascular disease or soft-tissue compromise in an attempt to avoid wound complications [52].

If these minimally invasive techniques are to be used, early treatment is indicated within 2 weeks due to early healing limiting fracture fragment mobility after this point [63]. Several studies have shown that minimally invasive approaches have decreased wound complications and secondary surgeries while having equivocal functional outcomes compared to ORIF [55, 57, 68].

In patients with severely comminuted Sanders type IV fractures, if ORIF alone is attempted, there is a high rate of clinically worse outcomes indicated by decreased AOFAS scores [69]. Sanders type IV fracture fixation can be done with ORIF alone, with some studies showing equal outcomes at 2-year follow-up when compared to ORIF with primary subtalar arthrodesis [69, 70]. However, beyond this time frame, there are decreased clinical outcomes utilizing the Short Form 36 version 2 (SF-36) scores requiring some patients with highly comminuted posterior facet calcaneus fractures treated with ORIF alone to undergo secondary subtalar arthrodesis [70]. Sanders et al. [43]. evaluated 10–20 year follow-up of ORIF treatment of Sanders type II and III fractures, showing a four times higher (18.6 vs. 47.4%) need for secondary subtalar fusion in type III fractures compared to that in type II fractures. Thus, some authors have suggested performing ORIF to restore height plus primary subtalar arthrodesis to avoid increased treatment costs and time off from work in fractures with higher degrees of comminution (**Figure 11**) [38]. However, it is difficult to predict which patients within this group of calcaneus fractures will develop chronic pain and eventually go on to arthrodesis, and this form of treatment can be a cause of its own downsides such as loss of motion and adjacent joint arthritis.

The importance of urgent reduction with percutaneous or open fixation of skin-threatening fractures cannot be overstated. Patients who sustain open fractures necessitating debridement and provisional stabilization and those with skin tenting, evolving wounds, or tongue-type/beak fractures should be initially splinted in

#### **Figure 11.**

*Primary subtalar fusion. (a) Highly comminuted intra-articular calcaneal fracture. (b) Harris view of the calcaneus after primary subtalar fusion. (c) Lateral view of the calcaneus after primary subtalar fusion.*

plantarflexion with abundant padding and then urgently addressed in the operating room in an attempt to prevent sequelae of skin necrosis and devastating wound complications.

External fixation is well described for calcaneus fractures in the literature as both a temporizing and definitive treatment option. With the high risk of soft-tissue complication with ORIF—even with minimally invasive approaches—external fixation has been further investigated as a treatment option. With the mechanism of action of calcaneus fractures primarily being due to high-energy trauma, the soft-tissue damage can be severe. Management often involves splinting the injury until the softtissue swelling has subsided. However, in more significantly displaced fractures, this delay in management can cause contraction of the soft tissues and preliminary callus formation [71–73]. These issues can combine to increase the overall difficulty of the surgical fixation for a calcaneus fracture [71–73]. As a result, there has been discussion in the literature of temporizing and definitive fixation of calcaneal fractures with external fixation.

Several external fixation methods have been proposed for calcaneal fractures, a testament to the lack of consensus and the overall difficulty of fracture management in these cases. Baumgaertel et al. described a minimally invasive external fixation approach of two-pin fixation, with one in each distal tibia and calcaneus to provide a distraction vector for the fracture, followed by lateral extensile ORIF [71]. The first pin is placed into the posterior calcaneus *via* a medial-to-lateral trajectory. The second pin is then placed either medial to lateral or anteriorly into the distal tibia. The pins are connected using an external fixator bar, and distraction force is applied. Overall alignment and reduction of the calcaneus is determined utilizing intraoperative X-ray and locked into position. The patients treated with external fixation followed by definitive fixation in their series had the external fixator in place for a median of 6.2 days [71]. The external fixator allowed for improved alignment and served as a reduction aid intraoperatively at the time of definitive fixation [71].

Githens et al. describe a medial-based fixator with pins in the proximal tibia, calcaneus, and midfoot to provide added construct stability while awaiting definitive fixation [73]. The first pin is placed across the midfoot medially, utilizing X-ray to ensure the tarsometatarsal joints are not violated with pin placement. The pin is placed across the medial, middle and into the body of the lateral cuneiform while under X-ray with a perfect AP view of the midfoot. The second pin is placed utilizing a medial to lateral trajectory into the distal tibia 1 cm above the incisura and parallel to the plafond. The third pin is placed into the calcaneus, typically the posterior tuberosity; however, the exact location of the pin can vary with fracture morphology. Importantly, the pin should be bicortical but not palpable on the lateral side. The first bar is placed between the tibia and the calcaneus, the second bar between the cuneiform and calcaneus, and the third between the tibia and cuneiforms (**Figure 12**) [73].

Ring frame external fixation combined with open operative approaches has been described in order to provide distraction, reduction of the articular surface, and internal fixation [74, 75]. Hou et al. describe the application of a ring frame external fixator utilizing 3, 2.5 mm Steinmann pins for fixation [75]. The first pin is placed transversely and perpendicular to the long axis of the tibia from lateral to medial at the junction of the middle and distal third of the tibia. The second pin is placed through the midfoot and the third through the posterior tuberosity of the calcaneus. The calcaneus and midfoot pins are each connected to separate half rings of the external fixator. The tibial pin is connected to a full ring of the external fixator. Connecting rods are placed between the tibial ring and the half rings of the midfoot and calcaneus. The midfoot

#### **Figure 12.**

*Calcaneus fracture external fixation technique as described by Githens et al. [73]. (a)-(c) sawbones demonstration of the medial-based calcaneal external fixator setup.*

and calcaneus half rings are joined *via* a single connecting rod directly inferior to the foot. Once the connecting rods are attached, they are left loose in order to perform the reduction. Utilizing intraoperative X-ray, the reduction is confirmed prior to locking the connecting rods. Once calcaneus length, height, Böhler's angle, and overall varus/ valgus alignment are confirmed to be satisfactory, the limb is no longer manipulated and allowed to rest for 10 minutes. The goal of the 10-minute rest is to allow soft-tissue relaxation. After 10 minutes, an extensile lateral approach is utilized for fracture fixation. Once fixation is achieved, the external fixator is removed [75]. The senior author of the current chapter (JTR) has utilized a similar ring frame construct utilizing skinny wires, half pins, and external fixator struts in order to bring the calcaneus fracture out to length as temporary or definitive management (**Figure 13**).

Fu et al. described a series of patients treated with fixator-assisted reduction. Their patients were initially treated conservatively with rest, elevation, ice, and

#### **Figure 13.**

*Calcaneus ring frame technique (JTR). (a) Preoperative X-rays. (b–d) Clinical pictures of ring frame, skinny wires/ tibial half pins, and struts. Wires are utilized for fixation into the calcaneal tuberosity and into the midfoot, while half pins provide tibial fixation. After rings have been connected to wires/pins, the calcaneus can be manipulated (pulled out to length and out of varus) and struts locked. (f–g) Postoperative external fixation X-rays.*

compressive bandages with planned operative management to follow [74]. Splinting materials were not used, and ankle and foot motion was encouraged to reduce swelling. Once the swelling had subsided, operative treatment was performed. A lateral extensile approach was utilized, and an external fixator was applied to aid in reduction. With their technique, two transcalcaneal full pins are placed in the posterior calcaneus, with two half pins placed anterior-posterior into the distal tibia (**Figure 14**). Once adequate internal fixation is achieved, the external fixator is locked with the ankle in a neutral position. The external fixator remains in place for approximately 3 months postoperatively [74].

Studies have also discussed using external fixation as the definitive treatment of these fractures. Checa-Betagón et al. described a series of 38 patients where external fixation was utilized as the definitive treatment [76]. In their series, they utilize a lateral-based external fixator (OrthoFix™ Calcaneal Fixator) with six half pins (3 pin clusters) placed into the calcaneus (posterior tuberosity, subchondral bone of

#### **Figure 14.**

*Calcaneus fracture external fixation technique as described by Fu et al. [74]. (a)–(c) sawbones demonstration of external fixator setup for use in fixator-assisted delayed ORIF.*

#### **Figure 15.**

*Calcaneus fracture external fixation technique as described by Checa-Betagón et al. [76]. (a) and (b) sawbones demonstration of the pin sites for lateral-based OrthoFix™ external fixator for use in definitive treatment.*

the posterior facet, or available subtalar surface) and the anterior tuberosity of the calcaneus or the cuboid (**Figure 15**). Pin clusters are placed in line with the X-ray beam when a perfect lateral view of each structure is seen individually. 69% of cases were reduced indirectly, while the remaining 31% required a minimal sinus tarsi approach or percutaneous k-wire joysticks to assist with reduction. They report results of external fixation to be similar to ORIF while reducing the risk of soft-tissue complication [76].
