Rev. bras. ortop. vol.52 número1

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

Article

Surgical

treatment

of

intraarticular

fractures

of

the

calcaneus:

comparison

between

flat

plate

and

calcaneal

plate

夽

Luiz

Carlos

Almeida

da

Silva

∗

_,

_João

_Mendonc¸a

_de

_Lima

_Heck,

Marcelo

Teodoro

Ezequiel

Guerra

UniversidadeLuteranadoBrasil(Ulbra),HospitalUniversitário,Canoas,RS,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received16February2016

Accepted2May2016

Availableonline29December2016

Keywords:

Calcaneus/injuries Calcaneus/surgery

Fractures,bone/surgery

Fracturefixation,internal

a

b

s

t

r

a

c

t

Objective:Toevaluatetheclinicalresultsofsurgicaltreatmentofintraarticularfracturesof

thecalcaneus,comparingtheuseofcalcanealplateandflatplate.

Methods:Thiswasaretrospectivestudyassessingthepostoperativeresultsof25patients

between2013and2015.Patientsundergoingsurgicaltreatmentofintraarticularfractures

ofthecalcaneuswithoutconcomitantsurgicallesionswereincluded.Patientswhodidnot

completeappropriatefollow-upaftersurgerywereexcludedfromthestudy.

Results:Theunavailabilityofcalcanealplatesatresource-limitedsettings,associatedwith

theavailabilityandlowercostofflatplates,mayhavebeenaconfoundingfactorinthe

presentstudy.However,therewasnostatisticaldifferencebetweentheoutcomesof

frac-turestreatedwithcalcanealplatesorflatplates.

Conclusion: Statisticalinferenceshowsthat,whencalcanealplatesarenotavailable,itis

possibletouseflatplateswithsimilarclinicaloutcomes.

eTraumatologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Tratamento

cirúrgico

das

fraturas

intra-articulares

do

calcâneo:

comparac¸ão

dos

resultados

entre

placa

reta

e

placa

própria

para

calcâneo

Palavras-chave:

Calcâneo/lesões Calcâneo/cirurgia

Fraturasósseas/cirurgia

Fixac¸ãointernadefraturas

r

e

s

u

m

o

Objetivo:Avaliarosresultadosclínicosdotratamentocirúrgicodasfraturasintra-articulares

docalcâneo(TCFIAC)ecompararousodeplacaprópriaparacalcâneo(PPC)eplacareta(PR).

Métodos:Estudoretrospectivoqueavaliouoresultadopós-operatóriode25pacientesentre

2013e2015.Foramincluídos pacientessubmetidosaoTCFIACequenãoapresentavam

lesõescirúrgicasconcomitantes.Pacientesquenãoforamdevidamenteacompanhadosno

pós-operatórioforamexcluídosdaanálise.

夽

StudyconductedattheUniversidadeLuteranadoBrasil(Ulbra),HospitalUniversitário,DepartamentodeOrtopediaeTraumatologia,

Canoas,RS,Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](L.C.Silva).

http://dx.doi.org/10.1016/j.rboe.2016.05.007

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Resultados: AindisponibilidadedaPPCemservic¸oscomrecursoslimitados,associadaà

disponibilidadeeaomenorcustodaPR,podetersidofatordeconfusãonopresenteestudo.

Contudo,nãohouvediferenc¸aestatísticaentreosresultadosdasfraturastratadascomPPC

ouPR.

Conclusão:Ainferênciaestatísticapermiteconcluirque,naausênciadaPPC,épossívelusar

aPRcomdesfechosclínicossemelhantes.

OrtopediaeTraumatologia.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND

(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Calcanealfracturescorrespondto2%ofskeletalfracturesand

about60%offracturesofthetarsalbones.1,2_Despite_the_great

developmentoforthopedictraumatologyinthelastcentury,

treatmentofthesefracturesisstillcontroversialandresults

areoftenunsatisfactory,duetothecomplexanatomicalshape

ofthecalcaneus,itscancellousstructure,andthefactthatitis

subjectedtoconstantweightload.3–6_Thus,_this_injury_causes

majorsocioeconomicandfunctionalimpairmenttopatients,

andrepresentsaburdentopublicandprivatecompensation

policies.1

Inrecentdecades,withtheimprovementofimaging

stud-ies,a better understanding of the mechanisms oftrauma,

andobservanceoftheprinciplesofanatomicalreductionand

absolute stability for joint fractures, it is now possible to

improve clinical outcome forthis typeoffracture. For this

purpose,severaltypesofimplantsareavailable,including

cal-canealplates(CP)andflatplates(FP).7

Therefore,this study aimedtoevaluatethe clinical

out-comesofsurgicaltreatmentofintra-articularfracturesofthe

calcaneus(STIAFC)andcomparetheuseofCPandFP.

Material

and

methods

Thiswasaretrospectivecohortstudy,whichevaluatedlate

postoperative resultsof 25 patients operatedbetween

Jan-uary 2013 and January 2015. This study was approved by

theResearchEthicsCommitteeunderNo.117817/2014/CAAE

40266114.9.0000.5328.

Inclusioncriteriacomprisedpatientswhounderwent

sur-gicaltreatmentbyopenreductionandinternalfixation(ORIF)

ofaunilateralcalcanealintra-articularclosedfracturewithout

otherassociatedfractures,whohadpreoperativecomputed

tomographyandradiographsofthefoot,ankle,andcalcaneus,

andwhohadsignedaninformedconsentform.

Exclusioncriteriawerepatientswhowereoperatedusing

theEssex-Loprestitechniqueorthoseinwhomaminimally

invasive surgery was performed; fractures treated

conser-vatively due to patient’s own reasons or lack of surgical

indication;associatedfractures;lackofadequate skin

con-dition,edema,andblistersinthelateral aspectofthefoot,

not resolved by the date of the surgery; absence of

clini-cal conditions due to vascular disorders, heart disease,or

decompensateddiabetes;severetraumaticbraininjury;

psy-chosocialproblem;heavysmoking;refusaltoundergosurgical

treatment;bilateralfractures;andrefusaltosigntheinform

consentform.

Duringthisperiod,64feetof52patientswereoperatedby

thesamesurgeon.Allpatientswerecalledforreevaluation;

25patientsundergoingSTIAFCmettheinclusioncriteriaand

wereincludedinthestudy.

Allpatientswereevaluatedbythesamesurgeonwho

per-formedallsurgeries.Thefollowingassessmentscales were

used:AmericanOrthopaedicFootandAnkleSociety(AOFAS),

theGlobalSocialFunctioningScale(GSFS),visualanalog(VAS),

andtheMedicalOutcomesStudy36(SF-36).8

Clinically, the followingaspectswere analyzed: subtalar

joint in the standing and supinepositions; varus and

val-gusdeviationofthehindfoot;abduction;adduction;pronation

andsupinationoftheforefoot;rangeofmotionforankle

flex-ionandextension;appearanceofsurgicalscars;andneedfor

crutches.Fortheclassificationoffractures,theSanders9_and

Essex-Lopresti10_{classifications}_were_used.

Similarly,allpatientsunderwentlatepostoperative

anal-ysis with radiographic study in Bröden’s view; calcaneus

radiographsinprofileand axial;bilateral radiographic

eval-uation of the feet with monopodal support; radiographic

evaluationoftheankleinprofile,anteroposterior,andin15◦_of

internalrotation;andbilateralcomputedtomographywith

5-mmthickaxial,coronal,andsagittalcuts.

Thesamplewasdividedintotwogroupsaccordingtothe

typeofORIFmade.GroupIconsistedofpatientstreatedwith

3.5-mmone-thirdtubularFP.GroupIIincludedpatients

under-goingtreatmentwithCP.

Thecriterionforthechoiceofmaterialwasrandomand

based onthepossibilityofusingCP,whichwasnotalways

available.Asfixationcriteria,isolatedFPortwocombinedFP

wereusedwhenCPwasnotavailable.CPwasusedwhenever

available.

AllpatientswereoperatedwiththeclassicL-shaped

lat-eralaccessroute,starting3cmfromtheposteriorregionof

thelateralmalleolus,passing3cmbelowthat,extendingto

thecalcaneocuboidjoint.Duetothehighriskofskin

necro-sis,dissectionwasmadeatthesubperiosteallevel.Theflap

wasfoldeddownandmaintainedcraniallywiththree2.0mm

Kirschnerwiresattachedtothetalus,withvisualizationofthe

sheathoftheperoneusmuscles, whichwaspreferably

pre-served.Underdirectvisualizationofthefracture,reduction

wascarriedout,withtemporaryfixationusingKirschnerwires

performedafterintraoperativeradiographicconfirmationof

thereduction.DefinitefixationwasmadewitheitherCPor

FP.Afterclosurebyplanes,anelasticcompressionbandage

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Table1–Demographicandclinicalcharacteristicsofthesample.

Typeofplate pa

CP(n=14) FP(n=11)

Age 47.7 10.4 45.5 11.29 0.617a

Sex 0.230

Female 3 21.4% 0 0.0%

Male 11 78.6% 11 100.0%

Traumamechanism 1.000

Bicycle×motorcyclecollision 1 7.1% 0 0.0%

Fallfromheight 13 92.9% 11 100.0%

Operatedside 0.414

Right 7 50% 8 72.7%

Left 7 50% 3 27.3%

Rearfootpositioninorthostasis 0.695

Neutral 8 57.1% 5 45.5%

Valgus 6 42.9% 6 54.5%

Subtalararthrosis 1.000

No 5 35.7% 3 27.3%

Yes 9 64.3% 8 72.7%

CP,calcanealplates;FP,flatplates.

a _p_-value_for_Fisher’s_exact_test.

weeks.Partialloadwasauthorizedatthesixthpostoperative

week.Autograftstofillthespacecreatedinsidethecalcaneus

werenotused.

Quantitative variables were described as mean and

standard deviation; categoricalvariables were described as

simple(n)andrelative(%)frequency.Toassessthemean

dif-ferencebetweentypesofmaterial,thet-testforindependent

samplestestwas used.To verify theexistenceofan

asso-ciationbetweentypesofmaterialandcategoricalvariables,

Fisher’sexact testwasused. Thesignificancelevel wasset

at5%.StatisticalanalyseswereperformedwithSPSSversion

18.0.

Results

Regardinggender,amongpatientsundergoingtreatmentwith

CP,11(78.6%)weremenandthree(21.4%)werewomen.Among

patientswhoweretreatedwithRP,11(100%)weremen.

Regardingtypeoftrauma,ofthepatientsundergoing

treat-mentwithCP,one(7.1%)hadsufferedtraumaduetoabicycle

collisionwithamotorcycleand13,fallfromheight;inturn,

all11(100%)patientstreatedwithFPhadsufferedafallfrom

height(Table1).

TheoperatedsideofpatientstreatedwithCPwastheright

sideinsevenpatients(50%)andleftinseven(50%).Among

patientsundergoingtreatmentwithFP,eight(72.7%)hadthe

rightsideoperatedandthree(27.3%),left.

Regardingthepostoperativepositionofthehindfootwhile

standing,amongpatientswhounderwenttreatmentwithCP,

eight(57.1%)presentedthehindfootinaneutralposition,and

six(42.9%),hindfootinvalgus.Inturn,amongpatientswho

underwenttreatmentwithFP,five(45.5%)presentedthe

hind-footinaneutralpositionandsix(54.5%)invalgus.

Regardingsubtalararthrosis,amongpatientswho

under-wenttreatmentwithCP,five(35.7%)evolvedwithoutsubtalar

arthrosisandnine(64.3%)presentedit.Amongpatientswho

underwenttreatmentwithRP,three(27.3%)evolvedwithout

subtalararthrosis,whileeight(72.7%)developedthecondition

(Table1).

Regardingtheclassificationoffractures,19patients(76%)

hadjointdepressionfractureandsix(24%),tongue-type

frac-ture.AsfortheSandersclassification,eight(32%)patientshad

type2Afracture;two(8%),type2B;six(24%),type3AB;three

(12%), type3AC;two(8%), type3BC;andfour (16%),type4

(Table2).

The results of both groups regarding waiting time for

surgery and physical examination are shown in Table 3.

Regarding clinical assessmentscales, Tables 4and 5 show

resultswithoutstatisticaldifferencebetweenthetwotypesof

plates.Therefore,therewasnodifferenceinclinicaloutcomes

betweenORIFinthecomparisonofCPandFP.

Table2–Classificationoffractures.

Typeofplate pa

CP(n=14) FP(n=11)

Essex-Lopresticlassification 0.350 Jointdepression 12 85.7% 7 63.6%

Tongue 2 14.3% 4 36.4%

Sandersclassification 0.655

2A 5 35.7% 3 27.3%

2B 1 7.1% 1 9.1%

3AB 2 14.3% 4 36.4%

3AC 3 21.4% 0 0%

3BC 1 7.1% 1 9.1%

4 2 14.3% 2 18.2%

CP,calcanealplates;FP,flatplates.

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Table3–Resultsofthegroupsinrelationtothewaitingtimeforsurgeryandmeasurementsofthephysicalexamination.

Typeofplate p

CP(n=14) FP(n=11)

Mean SD Mean SD

Waitingtimeuntilsurgery(days) 23.1 17.28 19.5 6.67 0.913a

Differenceincalfdiameter 1.9 0.53 1.5 1.35 0.308a

Widthofthehindfoot 6.7 0.71 7.1 0.82 0.270b

Ankleextension 11.5 10.41 11.8 7.17 0.67.6a

Ankleflexion 24.6 9.90 27.2 9.87 0.519b

Forefootsupination 13 12.88 20.7 11.19 0.084a

Forefootpronation 13.4 9.81 11.1 9.97 0.359a

Subtalarsupination 7.6 6.12 4 7.75 0.057a

Subtalarpronation 1 6.6 0.1 1.58 0.240a

Datapresentedasmeanandstandarddeviation(SD).CP,calcanealplates;FP,flatplates.

a _p_-value_for_{Mann–Whitney}_test. b _p_-value_for_independent_sample_t_-test.

Table4–Resultsassessedbytheclinicalassessmentscales.

Typeofplate p

CP(n=14) FP(n=11)

Mean SD Mean SD

PF-SF36ScaleScores 52.9 36.15 52.3 28.84 0.912a

RP-SF36ScaleScores 25.0 39.22 25.0 35.36 0.804a

BP-SF36ScaleScores 47.0 34.90 54.3 27.67 0.578b

GH-SF36ScaleScores 74.6 27.77 74.7 25.41 0.889a

VT-SF36ScaleScores 65.7 20.27 71.8 24.52 0.502b

SF-SF36ScaleScores 63.4 36.51 63.9 36.43 0.846a

RE-SF36ScaleScores 38.1 43.8 36.4 43.35 0.907a

MH-SF36ScaleScores 69.1 20.12 68.7 25.85 0.964b

PF-SF36Norm-basedScaleScores 37.4 15.15 37.1 12.10 0.967b

RP-SF36Norm-basedScaleScores 35.1 11.7 35.0 9.98 0.804a

BP-SF36Norm-basedScaleScores 40.0 14.94 43.2 11.85 0.575b

GH-SF36Norm-basedScaleScores 52.1 13.1 52.2 11.89 0.889a

VT-SF36Norm-basedScaleScores 54.1 9.61 57.0 11.62 0.502b

SF-SF36Norm-basedScaleScores 41.2 15.85 41.3 15.80 0.868a

RE-SF36Norm-basedScaleScores 35.8 13.61 35.2 13.70 0.907a

MH-SF36Norm-basedScaleScores 46.6 11.43 46.3 14.70 0.962b

PCS-SF36 38.1 13.37 39.2 9.47 0.817b

MCS-SF36 47.3 10.9 47.4 13.92 0.975b

Datawerepresentedasmeansandstandarddeviations(SD).CP,calcanealplates;FP,flatplates.

a _p_-value_for_{Mann–Whitney}_test. b _p_-value_for_independent_sample_t_-test.

Table5–Resultsaccordingtotheassessmentscales.

Typeofplate pa

CP(n=14) FP(n=11)

Mean SD Mean SD

VAS 4.6 2.73 3.6 2.38 0.344

AOFAS 66.1 26.37 52 20.64 0.160

Radiologicalwidthofthehindfoot 4.7 0.38 4.4 0.60 0.217

Pitchangleofthecalcaneus 21 5.88 16.6 5.66 0.74

Talusdeclinationangle 18 4.79 18.9 2.95 0.587

Datapresentedasmeanandstandarddeviation(SD).CP,calcanealplates;FP,flatplates.

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Discussion

Calcanealjointfractures aresevereinjuriesand maycause

permanentanddisablingsequelae.Theyusuallyaffectyoung

andeconomicallyactivemen,andthusthesefracturescan

haveanimportantsocioeconomicimpact.

Inthissample,wefoundthat88%ofpatientsweremale

andhad amean age of47.6 years.Accordingtothe

litera-ture,themostcommoncauseofintra-articularfracturesofthe

calcaneusisafallfromheight,1_which_was_confirmed_in_the

presentstudy,asthiscauseaccountedfor96%ofthefractures.

TheEssex-Lopresti10 _radiological _{classification}_is_a

clas-sical tool that determines the line of fracture and allows

treatment planning. Tomographic classifications help to

assesstheseverityandprognosisoftheinjury;theSanders

classificationisthemostcommonlyused.9 _However,

tomo-graphicclassificationsarenotuniformandeachgroupaims

tocreate its own classification,which makesit difficult to

compareresultsaswellastoidentifythetypeofinjurythey

describe.Tomographyisconsideredtobeanexcellenttestto

identifydetails ofthe fragmentsandthe jointimpairment;

however,itisnotavailableinallservices.Thislimitation

jus-tifiestheuseofaradiologicalclassification.

According to the Essex-Lopresti classification,

intra-articular fractures can be tongue-type or joint depression

type.In mostseries, joint depressionis the mostfrequent

type offracture, accounting for 43%–61% ofintra-articular

fractures.11,12_In_the_present_study,_76%_of_fractures_were_joint

depression-typeand24%,tongue-type.

For open surgery,there isa consensustowait between

sevenand 14 daysbetween traumaand operation, sothat

theedemareducesandblisterformationisprevented,except

inopen fractures,whichshouldreceive immediatesurgical

treatment,orwhenpercutaneousfixationisindicated.7,13_In

thepresentstudy,themeantimebetweentraumaand

oper-ationofthe25fractureswas23.1days(SD17.28)forCPand

19.5daysforFP(SD6.67).

Thelateral L-shapedaccessroute hasbeenwidelyused

because it allowsbetter visibility ofthe fracture, fragment

reduction,andinternalfixation.7,13_In_this_study,_the_extended

lateralL-shapedaccesswasefficient;itwasusedasastandard

techniqueforallcases.

Woundnecrosisisusuallytheresultofimproperincision

and exposureor long surgery.14 _Necrosis _is_observed _more

frequentlyin theend ofthe lateral L-shapedincision.15 _In

thepresentstudy,apatienttreatedwithCPneededsurgical

debridementduetoskinnecrosis,whichsolvedtheproblem

withouttheneedofaskingraft.

Symptomsassociatedwithimplantsproblems,whichare

rarelyreportedintheliterature,includeprominentimplant,

skinirritation,andheelpain.Problemsusuallyarisebecause

plate and screws cause irritation to the skin, tendons, or

nerves,orbecauseascrewpenetratesthefacetjoint.16,17

Ten-doninvolvementduetoimplantscanresultintendinitisor

rupture,andleadtotendinitisandsecondarypain.18_In_the

presentstudy,theCPhadtoberemovedinonepatientdueto

skinirritationandpain.Furthermore,inthreepatientswho

weretreatedwithFP,thesynthesismaterialhadtoberemoved

duetoFPandscrewprominence.

Theuseofbonegraftiscontroversial;someauthors

con-siderittobeosteoinductiveandosteoconductive,whileothers

consider itunnecessary.7,19 _It_is_noteworthy_that_the_use_of

bonegraft increasestheincidenceofmorbidity,asanother

incision ismade forgraft harvesting.In thepresent study,

bonegraftsfromtheiliacbonewerenotused.Instead,agraft

takenfromthelateralwallofthecalcaneuswasusedtofill

theremainingbonelossafterfracturereduction.

Assessing the resultsusing the AOFAS scale,the

litera-turepresentsratesofexcellentresults,rangingfrom42.22%

to62%.20–22 _In_this_study,_47.6%_of_the_results_were

consid-eredgoodorexcellent.Itisnotpossibletostatewithcertainty

thatthetypeoffracturemayhaveinfluencedthescore,asin

thepresentsample,thenumberoftongue-typefractureswas

smallwhencomparedwithjointdepression.

Post-traumaticarthrosisusuallyoccursinthesubtalarand

calcaneocuboidjoints.23 _The_literature_reports_an_incidence

rate of1.2%instudies withlong term follow-up.6,16 _When

intractablepaincannotbecontrolledbyanalgesics,subtalar

arthrodesismaybethebestoption.16_In_the_present_study,_one

patienttreatedwithFP,withafractureclassifiedasSanders4,

presentedintractablepainandunderwentsubtalar

arthrode-sis,whichimprovedthesymptoms.

Therearemanycontroversiesregardingthetypeofimplant

anditsselectioncriteria.ForORIF,moststudiesappliedaplate

tothelateralwallofthecalcaneus.24_Regarding_{stabilization}

screwsforthesustentaculumtali,therearealsocontroversies

regardingwhethertheyshouldbefixatedthroughtheplate.

PlatesinseveralshapescanbeusedforORIFofcalcaneal

frac-tures,anddifferenttypesofsyntheticmaterialsareadvocated

bydifferentauthors.24–30

Modernplateshavealowerprofile,whichhassolved

prob-lems related to excessive skin tension, prominence of the

implantundertheskin,andsubsequentdehiscenceofthe

sur-gicalwound.24_The_choice_for_a_lateral_plate_depends_on_the

severityofthecalcanealfractureand onbonequality.

Sim-plefracturesingoodqualityboneappeartobeadequatefor

FPfixation,whilecomplexfractureswithcomminutionmay

requireCPorevenlockingplates.24

FPhasbeenusedformanyyears.Intheearly1990s,due

topost-operativecomplicationsatthetime,ORIFtechniques

usingtwoFPsforfixationweredeveloped.Then,the

develop-mentofsingle,H-andY-shapedplatesstarted.30

The literaturefeatures numerousarticles on the use of

lockedplatewithminimallyinvasivetechnique.Fewstudies,

however,addresstheuseofFPforthetreatmentofcalcaneal

fractures,which,fortheBraziliansurgeon,isstillareality,due

tothecountry’shealthcaresystem.

Althoughthiswasaretrospectivestudy,ithelpedtoassess

theoutcomeofpatients.Itcanbeconcludedthattheresults

were very similar to those reported in the literature. The

present studyalsoindicatesthe needtodeveloptreatment

protocolsthatallowprospectivestudies,whichcouldprovide

morereliableinformationonfractures,bothpre-operatively

andduringtheirevolution.

AnotherimportantfactoristhatCPisnotalwaysavailable,

especiallyinpublicservicesthatfacefinancialdifficulties.In

turn,FPismorereadilyavailableandinexpensive.These

fac-tors impact surgicaltreatment. The unavailabilityofCP in

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ofFP,mayhavebeenconfoundingfactorinthepresentstudy.

However,thisstudydemonstratedthatthereappearstobeno

significantimpairmentinthetreatmentofcalcanealfractures

whenCPisnotavailable.

Conclusion

Statistical inference allowsfor the conclusion that, in the

absenceofCP,FPcanbeusedwithsimilarclinicaloutcomes.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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