Calcaneal fractures

Fusion and late reconstruction

Primary subtalar arthrodesis

Gallie (1943) suggested that the subtalar joint could not be reconstructed accurately enough to prevent arthritis developing and proposed primary posterior subtalar arthrodesis. Early series produced contradictory results. Sanders (1993) considers that severely comminuted fractures are probably best treated by primary arthrodesis after restoration of calcaneal height. Huefner et al (2001) reported six fractures treated in this way, five of whom got a good functional result.

Reconstructive fusion

A proportion of patients will develop disabling subtalar OA whatever their primary management. Buckley et al found this was five times more likely in those initially treated non-operatively. There are three main techniques available:

• fusion in situ, accepting some loss of heel height
• distraction fusion, using tricortical iliac crest graft to elevate the talus and restore heel height
• taking down the original fracture line, reconstructing calcaneal anatomy and fusing as close as possible to the original height

There are no RCTs comparing any of these methods. The Hanover group reported a retrospective comparison which did not show a significant difference in functional outcome between fusion in situ and distraction fusion. We therefore prefer to fuse in situ, unless there is anterior ankle impingement because of talar dorsiflexion, when distraction will correct talar alignment and the additional complexity and risk seems reasonable.

There is no evidence that primary subtalar fusion is better than initial non-surgical management (since highly-comminuted fractures did not do well in the Canadian trial) followed by late fusion in the patients (uncommon in our experience) who have disabling pain mainly or exclusively arising from the subtalar joint.

Collapse of the talus into the calcaneum after fixation of a highly comminuted calcaneal fracture. The patient had significant anterior ankle impingement	Intra-operative image. The subtalar joint remnant is taken down and the talus elevated with a laminar spreader or femoral distractor	Tricortical and cancellousgraft are used to maintain the correction. There has been about 10deg loss of correction at union but arthritic pain and impingment are minimal	Fusion in situ after calcaneal fracture. Although there is loss of height, the patient was satisfied to be rid of his arthritic pain and returned to work