[Surgical treatment of intra-articular calcaneal fractures].

PURPOSE OF THE STUDY The calcaneus is one of the most complex bones in the human body. If fractured, restoration of its anatomy is demanding and displaced fractures may have permanent consequences affecting both daily living and work activities of the patient. In this prospective study, the authors present the results of surgical treatment of 48 dislocated intra-articular fractures of the heel bone. MATERIAL In the period from September 2006 to September 2009, 48 dislocated intra-articular fractures in 41 patients were surgically treated at the Department of Trauma Surgery in Bratislava-Kramare. Seven (17 %) patients, six men and one woman, had bilateral calcaneal fractures. In the group of 41 patients, 32 (78 %) were men and nine (22 %) were women. The average age of the group was 41 years (range, 16 - 64 years). METHODS Based on computed tomography scans, the fractures (n=48) were classified according to the Sanders system into Sanders II to IV subgroups. This included 26 Sanders II fractures (54 %), 15 Sanders III fractures (31 %) and seven Sanders IV fractures (15 %). Minimally invasive reduction and osteosynthesis (MIOS) was used to treat 16 Sanders II fractures (33.33 %) and two Sanders IV fractures (4.16 %). Open reduction and internal fixation (ORIF) was employed in 10 Sanders II fractures (20.83 %), all 15 Sanders III fractures (31 %) and one Sanders IV fracture (2.08 %). Four comminuted fractures (8.33 %) classified as Sanders IV fractures were stabilised with an external fixator. The surgical technique was selected in accordance with the bone morphology, soft tissue condition and patient's overall state. RESULTS The patients were followed up for 6 to 36 months and clinical assessment was based on the Creighton Nebraska Health Foundation scoring system (C-N score) and the AOFAS Ankle-Hindfoot Scale (A-H score). The functional outcomes were excellent in 25 fractures (52 %), good in nine (18.75 %), less satisfactory in eight (16.6 %) and poor in six fractures (12.5 %). Complications of wound healing were recorded in three fractures (6.25 %) treated by ORIF, and only involved superficial marginal wound necrosis. There was no deep wound infection. Algodystrophic syndrome developed in two cases (4.16 %). X-ray measurements were used to assess the final Böhler's angle, whose value after treatment ranged from 8° to 38°, with an average of 27°. DISCUSSION At present the selection of an operative technique is being discussed. The advocates of MIOS emphasise a lower com- plication rate associated with wound healing and the possibility of using this technique when the treated tissues are in a critical condition. The advantage of ORIF lies in exact open reduction and stable osteosynthesis. CONCLUSIONS The method of percutaneous reduction and osteosynthesis is the optimal treatment for Sanders II dislocated fractures. Severely dislocated fractures (Sanders II and III) require open reduction and plate osteosynthesis. Comminuted fractures should be treated first by external fixation and by arthrodesis at the second stage if problems arise.