|Year : 2022 | Volume
| Issue : 7 | Page : 1143-1148
Management of calcaneus fractures by a new “Below-the-ankle” ilizarov frame: A series of 10 cases
D Li, S Yin, P Wu, M Gao, S Wen, Q Xu, J Mao
Department of Orthopedics and Traumatology, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Qinhuai District, Nanjing, China
|Date of Submission||23-Aug-2021|
|Date of Acceptance||12-May-2022|
|Date of Web Publication||20-Jul-2022|
Dr. J Mao
Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Qinhuai District, Nanjing - 210 004
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The optimal management of intra-articular calcaneal fractures is still controversial. Open reduction and internal fixation are always associated with serious complications. Aim: Various alternative methods have been used with variable effects. This retrospective study aimed to analyze the clinical efficacy and safety of a new “below-the-ankle” Ilizarov frame in patients with calcaneal fractures caused by high-energy trauma. Patients and Methods: We retrospectively explored ten patients with calcaneal fractures, of which four, five, and one were Sanders type II, III, and IV, respectively. All fractures were caused by high-energy trauma and were followed up for an average period of 21 months (range: 9–29 months). Clinical outcomes were primarily assessed by radiological criteria, functional scores of the foot and ankle, rate of complications, and ankle range of movement. Results: The Ilizarov frame was removed after an average period of 12 weeks (range: 11–15 weeks). Only two patients developed pin-tract infections, and none developed osteomyelitis, deep infections, neurovascular injury, malunion, and ankle arthrodesis. Based on the radiological assessment of the reduction of the subtalar joint and fracture fragments, all patients had excellent restored joint structure, with eight and two patients having good-to-excellent and fair ankle scores, respectively. The ranges of plantarflexion and dorsiflexion were 25°–43° and 8°–22°, respectively. Conclusion: The Ilizarov frame could be safe and effective for calcaneal fractures caused by high-energy trauma. This treatment protocol provides an effective approach to treat severe calcaneal fractures caused by high-energy events; however, long-term outcomes are still unknown.
Keywords: Calcaneal fracture, clinical, Ilizarov fixation, internal fixation
|How to cite this article:|
Li D, Yin S, Wu P, Gao M, Wen S, Xu Q, Mao J. Management of calcaneus fractures by a new “Below-the-ankle” ilizarov frame: A series of 10 cases. Niger J Clin Pract 2022;25:1143-8
|How to cite this URL:|
Li D, Yin S, Wu P, Gao M, Wen S, Xu Q, Mao J. Management of calcaneus fractures by a new “Below-the-ankle” ilizarov frame: A series of 10 cases. Niger J Clin Pract [serial online] 2022 [cited 2022 Aug 20];25:1143-8. Available from: https://www.njcponline.com/text.asp?2022/25/7/1143/351459
| Introduction|| |
Calcaneal fracture is one of the most commonly occurring tarsal fractures, which is mostly caused by high-energy injuries, such as falling from a height or motor vehicle accident. In cases where the talus hits the calcaneus under the combined effect of vertical compression force and shear force, enormous energy transmits through the calcaneal body, mostly resulting in severe soft-tissue injuries in calcaneal fractures., This injury wound is frequently open and contaminated and presents with marked swelling of the limb; hence, it is difficult to choose immediate and reliable treatments.
Recommended treatments of calcaneal fractures include closed manipulation reduction and application of plaster cast, percutaneous Kirschner-wire fixation, external fixation, primary arthrodesis, and open reduction and internal fixation (ORIF). In recent years, ORIF is becoming increasingly popular and is the current gold standard of treatment, and is renowned for providing excellent exposure, allowing direct reduction as well as strong fixation. However, multiple patients are not candidates for extensive incisions, limited by the soft-tissue conditions such as skin swelling and blisters, complete comminuted fractures, and open wounds. By the time the limb becomes fit for surgery, the patients may have missed a satisfactory reduction and may be subjected to early amputation and limb reconstruction. Percutaneous reduction and fixation and pin-to-bar unilateral or bilateral external fixators or circular frames have been reported for severely comminuted fractures in order to address these well-known pitfalls encountered with open techniques.,,,,,,,
The use of Ilizarov circular frames for indirect reduction and stabilization of calcaneal fractures has been reported in previous studies. This method has shown satisfactory functional and radiographic results in a short time compared to traditional ORIF techniques. However, all frames proposed in previous case reports were ankle-spanning and were constructed to immobilize both ankle and subtalar joints to achieve stable fixation.
Ilizarov frames, as a classical surgery technology, have been used in severely injured heels with soft-tissue damage and partial bone comminution., Therefore, in this study, we have developed a new “below-the-ankle” frame for indirect reduction by wire prying and stabilization of the fractures to further minimize trauma, complications, secondary procedures and to pursue an alternative treatment that can be used for future calcaneal fractures.
| Material and Methods|| |
We reviewed ten displaced calcaneal fractures in our institution from 2018 to 2020. The general information and clinical outcomes of patients are shown in [Table 1]. All patients underwent surgical repair by a below-the-ankle Ilizarov frame for indirect reduction through wire prying and stabilization of the fractures, and each patient was evaluated retrospectively through electronic medical records. We assessed the quality of fracture reduction by radiological features of the fracture, preoperatively and postoperatively, and at their latest follow-up (Böhler's angle, Gissane's angle, length, axis, as well as subtalar joint space), and by a rate of complications and standardized questionnaires (American Orthopedic Foot and Ankle score and the extent of patients satisfaction).
Computed tomography scan
Preoperative and postoperative imaging of the calcaneus fractures, which included plain axial and lateral radiography, and computed tomography [Figure 1], helped us in decision making and preoperative planning of distraction and displacement direction. The placement and distribution of the calcaneal wires were crucial, which largely determined the need of open reduction and fixation of the articular surfaces. Meanwhile, we also paid attention to the possibility of neurovascular injury, osteomyelitis or deep infections at the time of fracture healing. We evaluated ankle-hindfoot function based on the American Orthopedic Foot and Ankle Society Score as excellent (90–100), good (75–89), fair (50–74), and poor (<50).
|Figure 1: Preoperative and postoperative axial computed tomography scan. (a-b) Preoperative lateral radiograph. (c-d) Postoperative lateral radiograph|
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Small wire circular frames were used on all patients. The patient was placed on an operating table in the lateral position. A tourniquet was applied to prevent bleeding, depending on the partial soft-tissue condition and fracture type.
First, one or two 4.0 wire were inserted under the fluoroscopic control through the medial aspect of the calcaneus bone to the most posterior and intact segment of the calcaneal tuberosity, depending on the fracture type and degree of comminution. The wire was adjusted to pry near the major fragments of the calcaneus and pushed them back in place. It is crucial to pry the calcaneal wires to reduce fracture and to correct a great part of the varus deformity of the tuberosity.
Then, a second 4.0 olive wire was inserted from the posterior subtalar joint articular surface to the distal portion of the fracture line, followed by reduction of the axis and height of the calcaneal body by indirect manual manipulation through wire prying. Using the gradual distraction, Böhler's and Gissane's angles were easily restored. Distraction between the talus and the calcaneusv rings was achieved using threaded rods.
Then, the posterior facet was reduced if needed. A small incision of 1.5–2 cm just anterior to the tip of the lateral malleolus reduces the major articular fragment of the posterior facet under fluoroscopic control.
Then, after the desired reduction was confirmed through radiography, 4–6 olive wires were inserted percutaneously from the medial, lateral, and posterior cortex bodies of the calcaneus, depending on the fracture type and degree of comminution, which passed through the reduced fragment. When wires were inserted through calcaneal out, no wires were inserted through talus and subtalar joint was kept free [Figure 2].
|Figure 2: Clinical photograph of the limb on the first postoperative day. (a) and (b) The movement of plantar flexion and dorsiflexion are seen at (c) and (d) show the posterior and anterior general view|
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After fluoroscopic reconfirmation of adequate reduction, the superior 5/8 half ring was locked into place by connecting the rings to each other with 4–6 threaded rods. Postoperatively, patients were encouraged to perform ankle Range of movement (ROM) exercises and to start with partial weight-bearing as tolerated. All patients with calcaneal fracture had healed fractures in a mean of 12 weeks (range: 10–15 weeks), and the Ilizarov frame was removed in an average of 12 weeks. All patients were followed up for an average of 21 months (range: 9–29 months), and the mean time of clinical and radiological union was 12 weeks (range: 10–15 weeks).
| Results|| |
The patients' preoperative average Böhler's angle, Gissane's angle, and length, height, width and subtalar joint space of the calcaneus were 17.3° (10.9°–36.7°), 100.5° (87.4°–124.8°), 7.1 cm (6.2–8.24 cm), 3.9 cm (3.06–4.41 cm), 3.5 cm (2.85–4.7 cm) and 2.8 mm (2.4–3.5 mm), respectively, and the average postoperative measurements were 25.9° (12.9°–38°), 109.5° (91.1°–123.2°), 7.7 cm (7.13–8.31 cm), 4.06 cm (3.66–5.06 cm), 4.6 cm (3.38–5.54 cm) and 2.4 mm (1.97–3.3 mm), respectively [Table 2].
|Table 2: Average of radiological outcomes before and after the operation|
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Considering the use of the below-the-ankle Ilizarov frame, reduction techniques, and olive wires mounted on the reference ring, no significant postoperative complications occurred. Only two patients developed superficial pin-tract infections, which were treated successfully with oral antibiotics. None had osteomyelitis or deep infections, or nerve injury, malunion, and ankle arthrodesis from the pins.
We assessed patients' functional status by the American Orthopedic Foot and Ankle score. Eight and two patients had good-to-excellent and fair ankle scores, respectively. A total of eight patients (80%) regained ankle dorsiflexion of ≥10°, and two achieved dorsiflexion between 5°–10°. Plantar flexion was ≥30° in eight patients (80%), and 25°–30° in two patients. The average movements of ankle joint ranged from 25°–41° of plantar flexion and 9°–22° of dorsiflexion [Table 3].
Patients reported satisfaction using the 100-mm Visual Analogue Scale (0 mm = totally unsatisfied, 100 mm = completely satisfied). The mean patient satisfaction was 86 (range: 83–96), and all patients resumed to daily work. In addition, there were no patients who required secondary procedures [Table 3].
| Discussion|| |
Calcaneal fractures are complex and intractable, accounting for approximately 5% of all lower extremity fractures. These are usually caused by high-energy events, such as falling from a height or motor vehicle accidents, which are often associated with severe soft-tissue injuries and complications. During the past few decades, we have witnessed the changing trends in the management of these injuries, such as closed manipulation, intramedullary nail, external fixation, Kirschner's wires, and synthesis with modern plates. No single treatment protocol can satisfactorily treat the various calcaneal fractures.
With the development of internal fixation technology, it seems that ORIF through an extensive lateral approach has become an increasingly standardized and effective treatment of choice for calcaneal fractures. ORIF has the advantage of excellent exposure to the posterior facet, lateral wall, calcaneocuboid joint, and tuberosity. However, the pitfalls and limitations cannot be ignored. The most common complications are wound healing problems and infections, which are associated with severe soft-tissue swelling. McGarvey et al. reported failure of improvement in patients treated with ORIF and increased complication rates. Moreover, ORIF procedures are not always viable, especially when the skin condition is poor because of excessive swelling or blisters, and in complete comminuted fractures. Considering this issue, minimally invasive osteosynthesis and indirect reduction have aroused increasingly widespread concern. Several authors have used a fine wire circular frame to treat displaced intra-articular calcaneal fractures. Malizos et al. described a new technique for reduction and stabilization of calcaneal fractures with an Ilizarov frame. Emara et al. compared Ilizarov fixation with ORIF in calcaneal fractures; and despite the deteriorated skin condition, the outcomes were comparable, with fewer complications in the Ilizarov group.
Anatomic reduction of the subtalar joint and the geometry of the calcaneus are of significant importance to obtain good functional reconstruction and delay disabling arthritic symptoms in the subtalar joint. Several authors have suggested that radiological images were not always consistent with functional outcomes., Despite good radiological reduction, poorer results may occur, which may be attributed in part to the severity of injury to the subtalar articular cartilage at the time of fracture., This is also one advantage of circular frame use over internal fixation, as the use of Ilizarov fixator in treating calcaneal fractures allows restoration of length, width, and height of the hindfoot, stabilization of limb, decreased risk of deep infection and skin necrosis, as well as better functional outcomes and cosmetic appearance.,
Treatment of calf fractures involves stabilization of the lower tibia and immobilization of the ankle joint, which is called a traditional circular frame. The technique used in our study, called “below-the-ankle” frame, reduced indirectly by prying and stabilizing the fracture with wires to further reduce trauma. The management of calcaneal fractures caused by high-energy trauma, using a “below-the-ankle” Ilizarov fixator has the great advantage of indirect reduction by wire prying. Stability and ultimate fixation were achieved with or without minimal invasive incision. The configuration of the Ilizarov frame used in our study is lightweight and consists of 5/8 half-rings locked into place using 4-6 threaded rods. In our experience, the “below-the-ankle” frame is easy to apply, and reduction of the shape and height of the calcaneus is relatively easy using gradual distraction.
Malizos et al. and Dimitroulias and Harbacheuski. reported a new technique for the reduction and stabilization of calcaneal fractures with an Ilizarov frame, which sought to avoid this issue by proposing the use of frames constructed entirely below the level of the ankle joint, with wires placed through the talus and midfoot instead of the tibia.,, Traditional external fixators or circular frames without spanning the ankle joint have the distinct disadvantage of unpredictable ankle joint stiffness and contractures, in addition to wire-related complications of the tendons and neurovascular structures of the lower third of the tibia, when the patient was immobilized in the frame for several months. Additionally, on account of avoiding place wires inserted from the talus and subtalar joint, the incidence rate of subtalar arthritis can be vastly reduced. Moreover, we cannot ignore the fact that it is a technically demanding procedure that requires specialist training, which perhaps limits its widespread use for the fixation of large numbers of calcaneal fractures.
It is worth mentioning that early stimulation of the heel through weight bearing can reduce the incidence of complications, such as subtalar fusion, chronic heel pad pain, and complex regional pain syndrome after calcaneal fractures. Besides, our “below-the-ankle” frame allows continuous distraction of the subtalar joint during the healing process, which has a positive effect on delaying disabling arthritic symptoms in the subtalar joint. The rigidity of fixation can be adjusted to suit the stage of fracture healing and allow correction of the deformity.
In our study, we retrospectively explored ten calcaneal fracture patients with a new “below-the-ankle” frame. Although there is no clear evidence to delineate the best management for this type of fractures, our results show no secondary reconstruction procedures, no osteomyelitis or deep infections, and only one case of superficial pin-tract infection that subsided within an average of eight weeks of fracture fixation. Based on radiological outcome, the Böhler angle, Gissane angle, calcaneal width, and calcaneal function recovered to clinically acceptable levels in all patients. Functional outcome score based on the American Orthopedic Foot score was fair and over. All the patients resumed daily work. Stable fixation with a low complication rate and good function can be achieved by using Steinmann pin to pry and a “below-the-ankle” frame to reduce and stabilize the fracture, with a minimal incision as and when required. This technique can be used in almost every patient with an intra-articular calcaneal fracture, especially if the skin condition is not suitable for an ORIF.
Financial support and sponsorship
The third batch of peak academic talent project of Jiangsu Provincial Hospital of Traditional Chinese Medicine (second level) (No.: y2021rc20).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sangeorzan BJ, Benirschke SK, Car JB. Surgical management of fractures of the os calcis. Instr Course Lect 1995;44:359-70.
Gaudinez RF, Mallik AR, Szporn M. Hybrid external fixation in tibial plafond fractures. Clin Orthop Relat Res 1996:223-32. doi: 10.1097/00003086-199608000-00028.
Sommer C, Ruedi TP. Tibia: Distal (Pilon). In: Reudi TP, Murphy WM, editors. AO Principles of Fracture Management. Vol 2. New York: Thieme; 2000. p. 539-56.
Ovadia DN, Beals RK. Fractures of the tibial plafond. J Bone Joint Surg Am 1986;68:543-51.
Böhler L. Diagnosis, pathology, and treatment of fractures of the os calcis. J Bone Joint Surg 1931;13:75-89.
Rammelt S, Amlang M, Bartel S, Zwipp H. Minimally-invasive treatment of calcaneal fractures. Injury 2004;35(Suppl 2):SB55-63.
Mangan B, Bortolazzi R, Marangon A, Marino M, Dall'Oca C, Bartolozzi P. External fixation for displaced intra-articular fractures of the calcaneum. J Bone Joint Surg Br 2006;88:1474-9.
Githens M, Shatsky J, Agel J, Bransford RJ, Benirschke SK. Medial external fixation for staged treatment of closed calcaneus fractures: Surgical technique and case series. J Orthop Surg (Hong Kong) 2017;25:2309499017727915.
Roukis TS, Wunschel M, Lutz HP, Kirschner P, Zgonis T. Treatment of displaced intra-articular calcaneal fractures with triangular tube-to-bar external fixation: Long-term clinical follow-up and radiographic analysis. Clin Podiatr Med Surg 2008;25:285-99.
Dayton P, Feilmeier M, Hensley NL. Technique for minimally invasive reduction of calcaneal fractures using small bilateral external fixation. J Foot Ankle Surg 2014;53:376-82.
Paley D, Fischgrund J. Open reduction and circular external fixation of intra-articular calcaneal fractures. Clin Orthop 1993;290:125-31.
Schwartsman V, Schwartsman R. Reduction techniques with the Ilizarov frame for calcaneal fractures. Tech Orthop 2002;17:185-96.
Gupta V, Kapoor S, Clubb S, Davies M, Blundell C. Treatment of bilateral open calcaneal fractures with Ilizarov frames. Injury 2005;25:1488-90.
Gur E, Atesalp S, Basbozkurt M, Aydogan N, Erler K. Treatment of complex calcaneal fractures with bony defects from land mine blast injuries with a circular external fixator. Foot Ankle Int 1999;20:37-41.
Schneider W, Jurenitsch S. Normative data for the American orthopedic foot and Ankle Society ankle-hindfoot, midfoot, hallux and lesser toes clinical rating system. Int Orthop 2016;40:301-6.
Coughlin MJ. Calcaneal fractures in the industrial patient. Foot Ankle Int 2000;21:896-905.
McGarvey W, Burris M, Clanton T, Melissinos E. Calcaneal fractures: Indirect reduction and external fixation. Foot Ankle Int 2006;27:494-9.
Malizos K, Bargiotas K, Papatheodorou L. The Below-the-Ankle circular frame: A new technique for the treatment of displaced calcaneal fractures. J Foot Ankle Surg 2006;45:295-9.
Emara K, Allam M. Management of calcaneal fracture using the Ilizarov technique. Clin Orthop Rel Res 2004;439:215-20.
Mauffrey C, Klutts P, Seligson D. The use of circular fine wire frames for the treatment of displaced intra-articular calcaneal fractures. J Orthop Traumatol 2009;10:9-15.
McGarvey WC, Burris MW, Clanton TO, Melissinos EG. Calcaneal fractures: indirect reduction and external fixation. Foot Ankle Int. 2006;27:494-9.
El-Mofawi H, Abdulsaad MS, Abd-el-naby WL, Kandil YR. Closed reduction of displaced intra-articular calcaneal fractures using Ilizarov frame. J Limb Lengthening Reconstr 2017;3:57-64.
Lehmann S, Murphy RD, Hodor L. Partial calcanectomy in the treatment of chronic heel ulceration. J Am Podiatr Med Assoc 2001;91:369-72.
Su Y, Chen W, Zhang Q, Liu S, Zhang T, Zhang Y. Bony destructive injuries of the calcaneus: Long-term results of a minimally invasive procedure followed by early functional exercise: A retrospective study. BMC Surg 2014;14:19.
Dimitroulias A, Harbacheuski R. Ipsilateral pilon and Calcaneus fractures: Treatment with circular frame without spanning ankle joint. Strategies Trauma Limb Reconstr 2019;14:111-4.
Muir RL, Forrester R, Sharma H. Fine wire circular fixation for displaced intra-articular calcaneal fractures: A systematic review. J Foot Ankle Surg 2019;58:755-61.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]