Abstract
Objective
To review postoperative complications reported after closed calcaneus fracture treated by open reduction and internal fixation (ORIF).
Methods
Postoperative complications reported in the literature between 1995 and 2012 were identified. Papers were retrieved from publicly available databases and included in this study if they met the following criteria: clinical research of cases of closed calcaneus fracture treated by ORIF; ≥10 cases; detailed information about complications, treatment and follow up.
Results
Twenty-one clinical reports were analysed (2046 cases). Reported complications (and incidence rates) were: infection and skin flap necrosis (13.6%); neurovascular injury (2.8%); post-traumatic arthritis (1.2%); malreduction/implant problems (0.8%); nonunion (0.1%).
Conclusions
Postoperative complications after closed calcaneus fracture are common clinical problems that cannot always be avoided. They can even be life altering, due to the requirement for long-term treatment or amputation and their economic impact on the patient. Complications should be diagnosed and treated promptly, to achieve satisfactory outcomes. Nonsurgical treatment (e.g. local wound care, drugs or physical therapy) can be attempted. If such measures fail, surgical treatment (e.g. debridement, skin flap transplantation, implant removal, re-opening of the reduction and internal fixation or subtalar joint arthrodesis) should be considered.
Keywords
Introduction
Since the 1990s, the surgical treatment of closed calcaneus fracture by open reduction and internal fixation (ORIF) has become widely accepted. The main objectives of the ORIF procedure are to achieve realignment of the posterior facet of the subtalar joint and to recover the height of the hindfoot. ORIF has substantial advantages over earlier techniques (such as closed reduction and pinning with the Steinmann pin, or the Essex-Lopersti technique), because it reduces and fixes the fracture, recovers the normal morphological structure and biomechanics of the foot, and prevents pain and stiffness of the subtalar joint by facilitating motion of the foot within 6 weeks postoperatively. In addition, ORIF decreases pain early in the postoperative period, partly due to the early mobilization that is possible following this procedure. With techniques that do not involve percutaneous reduction, patients commonly experience more pain than they do with ORIF, due to the longer wound and deeper dissection that are necessary aspects of other procedures. 1
However, there are particular postoperative complications associated with ORIF (the main ones being infection and skin flap necrosis, neurovascular injury, malreduction and implant problems, post-traumatic arthritis and nonunion): such complications can lead to considerable disability, as indicated by lower functional scores being obtained by patients on American Orthopaedic Foot and Ankle Society hindfoot scoring systems. 2 Furthermore, such complications may be life altering, not only because of the symptoms but also because of the economic burden they place on the patient. 3 Therefore, the prevention and treatment of postoperative complications following ORIF are both important aspects of care.
The present review studied published reports of postoperative complications in closed calcaneus fracture treated by ORIF, to calculate the incidence rates, find the main reasons for such complications and identify the best clinical treatment strategies for their management.
Materials and methods
Literature retrieval
This study searched the publication databases PubMed®, Medline®, Cochrane, Elsevier and Ovid using the search terms ‘calcaneus fracture’, ‘calcaneal fracture’, ‘OS calcis fracture’, ‘heel fracture’ and ‘complications’. The search was restricted to English-language journals.
Inclusion and exclusion criteria
Inclusion criteria were defined as follows: clinical research of cases of closed calcaneus fracture treated with ORIF; publication between January 1995 and December 2012; assessment of ≥10 cases; detailed information about complications, treatment methods and follow up. Articles were excluded if they were a systematic review, constituted anatomical or biomechanical research or assessed <10 cases.
Literature analysis
All authors of the present paper reviewed the data from the articles independently. Consensus on which complications were being reported was reached either after review, or by discussion and consultation of Campbell’s Operative Orthopaedics (11th edn) 4 and Rockwood and Green’s Fractures in Adults (7th edn). 5 If no consensus was reached, the data were not included in the study.
Statistical analyses were not undertaken, however, because none of the articles was a prospective randomized control trial. Consequently, this study was not a meta-analysis.
Results
Summary of the findings of 21 publications reviewed in the present study, reporting postoperative complications reported after closed calcaneus fracture treated by open reduction and internal fixation (ORIF). Publications were included if they: reported clinical research of cases of closed calcaneus fracture treated with ORIF; were published between January 1995 and December 2012; included ≥10 cases; provided detailed information about complications, treatment methods and follow up.
, Treatment not reported.
Most of the articles included in this study described the causes of (and risk factors and potential treatments for) infection, in detail. Briefly, the studies confirmed that the outer layer of soft tissue is the most prone to infection, probably because blood is supplied to the lateral calcaneus solely by the lateral calcaneal artery and, thus, is more likely to develop hypoxia after injury. 22 In addition, the lateral calcaneus has a soft-tissue structure that is thinner than that of other bones, which may also make it more prone to postoperative infection. 2 The timing of surgery is also an important factor. For example, Buckley et al. 11 believed soft-tissue management to be critical; they did not recommend early surgery. In addition, Abidi et al. 20 concluded that there was a relationship between timing of surgery and infection (i.e. infection rate was substantially increased if surgery was done ≥5 days after the injury). Superficial infections were recommended to be treated by local wound care, debridement, changing dressings daily with povidone iodine, and using intravenous antibiotics according to bacterial culture results. 14 With severe osteomyelitis (i.e. diffused to the whole calcaneus), one paper recommended that all implants should be removed, rigorous debridement should be undertaken (to remove as much of the infected or necrotic tissue and bones as possible), and the third-generation antibiotic cephalosporin should be administered for 6 weeks. 19 Regarding the remaining bones, if most of the calcaneus could be retained after debridement, hindfoot arthrodesis could be considered. However, in situations where osteomyelitis is diffused to most parts of the foot and bones cannot be preserved, amputation should be considered.19,22 If the wound is exposed, strategies involving distant skin flap transfer should be used. 20
Skin flap necrosis is usually the result of improper incision and exposure, or a lengthy time taken for distraction. 13 Necrosis is most often observed at the corner of the lateral L-shaped incision, possibly related to the areas supplied by the peroneal artery. 2 To prevent skin flap necrosis, the incision should be curved and the exposure should go from the skin flap to the periosteum directly by sharp dissection, without distraction; finally, the incision should be sutured without tension. 15 If skin flap necrosis occurs, debridement of all necrotic tissue and changing dressings with thick povidone iodine gauze once a day often results in a good outcome. 17 However, if the necrotic area is >3.5 cm wide, skin flap transplantation might be needed. 15 One paper concluded that a reversed sural nerve flap is most frequently used because of its rich blood supply and the simplicity of the operation. 15
In the present analysis, 34 patients had nerve injury, of whom 11 had heel numbness and nine had sural nerve damage symptoms. In Chan and Ip, 9 there were three cases of sural nerve damage and three cases of reflex sympathetic dystrophy, all of which recovered following nerve block and neurotrophic drug therapy: Chan and Ip did not report the specific therapies used in their cases, 9 but in our clinical experience we would have selected a neurotrophic agent such as mecobalamin. In Raymakers et al., 12 two cases suffered from tibialis posterior nerve pain: one patient self-healed 6 months later and the other achieved an improved prognosis after neurectomy.
Malreduction and implant problems were reported in some studies: one paper found that they directly resulted in malunion and post-traumatic arthritis. 9 Secondary surgery was always necessary following such problems, and these procedures included the removal of the implants and re-ORIF, unless the symptoms could be managed by nonsurgical treatment. 17
One paper found that malreduction could be best avoided by using a curved periosteal elevator and inserting it into the compressive bone blocks of the posterior articular facet, then levering the fracture up in order to see clearly and restoring the congruity of the subtalar joint facet. 7 With this procedure, the congruity of facets and the height of the hindfoot could be restored. Malreduction always requires revision surgery if the subtalar facet remains collapsed and the Böhler angle and Gissane angle are not recovered after ORIF. According to our experience, if malreduction could be diagnosed within 6 weeks after initial ORIF, re-ORIF could be attempted. Otherwise, salvage surgery (e.g. subtalar arthrodesis) should be considered.
Symptoms associated with implant problems, which were rarely reported in the papers, included prominent fixation, skin irritation and heel pain. Problems generally arose because the plate and screws had irritated the skin, tendons or nerve, or because the screws penetrated the articular facet.10,11 Irritation of the tendons could result in tendinitis or tendon rupture, leading to peroneal tendinitis, malfunction and secondary pain. 7
Post-traumatic arthritis was considered as a problem in one study because it caused intractable pain. 15 Post-traumatic arthritis also occurred because of improper reduction of the subtalar joint, residual fragments in the articular facet, or cartilage damage caused by the initial injury and implant penetration. 12 Zwipp et al. 2 reported that post-traumatic arthritis occurred below the ankle joint in about one-half of cases, and in the calcaneocuboid joint in about one-fifth of cases. Even if the joints could be reduced, articular cartilage may have been damaged with the initial injury, gradually leading to irreversible problems: 2 in this paper, the authors concluded that degenerative changes initially occurred in the subtalar and calcaneocuboid joints, then progressed to the ankle joint. 2 In such situations, conservative or nonsurgical treatments were often attempted first; if these failed, surgical interventions (including the removal of the implant, and subtalar and calcaneocuboid arthrodesis) were undertaken.10,17
Nonunion was rarely reported in the included studies of calcaneal ORIF. However, for the few cases of nonunion that were described, surgery may have damaged the blood supply. 16 In two studies, two patients obtained complete healing of nonunion by undergoing bone grafting in a secondary operation.16,17
Discussion
Delayed or missed diagnosis of postoperative complications of calcaneus fracture may cause malfunction of the foot and lead to a life-altering event for some patients. In the present study, we assessed 21 articles to find out the incidence rates – and the causes and treatment – of postoperative complications after closed calcaneus fracture.
High incidence of postoperative infection is a primary concern for surgeons, 25 with infection and skin flap necrosis being the most commonly seen complications. We calculated the incidence rate in all included studies as being 13.6%, which varied from the rate quoted elsewhere: Tennent et al. 3 , and Geel and Flemister 6 reported infection rates of 0.3% and 22%, respectively. The differences may be due to differences in the original injury, unfamiliarity with anatomy or inappropriate perioperative management. Therefore, the choice of surgical approach and the timing of surgery should be noted in future reports. 2 When infection or skin flap necrosis occurs, local wound care, debridement, changing dressings, antibiotics and skin flap transplantation should be attempted – in that order – with a favourable outcome being largely dependent on early diagnosis and treatment. 8
In calcaneal surgery, the most common injury appears to be sensory nerve damage. 26 Neurovascular injury is an iatrogenic injury that is rarely seen postoperatively, and a definite incidence rate has not been reported. In the 21 papers included here, we calculated the incidence rate to be 2.8%. In terms of specific injuries that are observed following calcaneal surgery, the lateral approach may lead to sural nerve injury, whereas the medial approach can cause damage to the neurovascular system from the branch of the posterior tibial nerve onwards, especially the calcaneus branch of the tibial nerve (which dominates the heel pad). 18 Nerve injury can manifest as heel numbness, tibial nerve and sural nerve damage symptoms, and neuroma formation. 27 In some patients injury may be self healing; in others, nonsurgical treatment, such as physical or neurotrophic therapy, should be attempted. However, patients with substantial symptoms (such as pain, or neuroma) or those with neurolysis may require further surgery. 18 Certainly, nerve block or neurectomy could be considered for those with tibialis posterior nerve pain or sural nerve damage. 12
Malreduction may result from an intra-articular comminuted calcaneus fracture, an improper reduction technique or the use of nonstandard fluoroscopy (i.e. incorrect positioning of the foot, leading to nonstandard lateral or axial views of the calcaneus) during the operation. 28 Malreduction can easily lead to calcaneal malunion. 28 Although we calculated the incidence rate for malreduction as being only 0.8%, secondary surgery is always needed, including the removal of implants and re-ORIF unless the symptoms can be managed by nonsurgical treatment. 17
The incidence of implant problems can be reduced by using implants that are smaller in size and thinner, compared with standard implants: these smaller implants can be placed through smaller incisions. 29 With less serious implant problems, such as occasional local pain, nonsurgical treatments including nonsteroidal anti-inflammatory drugs and physical therapy can be attempted. 30 In addition, if nonsurgical treatment is unsuccessful or if symptoms are severe or worsen, early surgical removal of the implant should be performed. 17 However, in the authors’ opinions, the incidence of implant problems is quite low, and the rates of implant failure and loosening have yet to be reported. It is possible that the low incidence of implant problems is a result of improvements in intraoperative fluoroscopy techniques, and the early diagnosis and treatment of implant-related problems that are observed.
Post-traumatic arthritis commonly occurs in the subtalar and calcaneocuboid joints. 31 We calculated an incidence rate of 1.2%; in the included papers, but the rate rises with longer follow up because of irreversible articular cartilage damage and degenerative changes. 10 When intractable pain cannot be controlled by analgesic drugs, subtalar joint arthrodesis may be the best choice.10,17
Nonunion is an infrequent postoperative complication: we calculated the incidence rate as only 0.1%. Molloy et al. 32 reported that the following factors explain its low incidence: most calcaneus fractures are operated on using the lateral approach, therefore only the branches of the peroneal artery may be damaged (the extended lateral incision avoids damage to the blood supply of the calcaneus); in addition, the calcaneus is cancellous bone with a rich blood supply. Bone or soft tissue infection may also cause nonunion, and nonunion will cause loss of the plantigrade function. 33 Nonunion can easily occur secondary to malreduction and infection, but re-ORIF with bone grafting may salvage foot function.16,17
The present literature review excluded articles published prior to 1995, systematic reviews and anatomic or biomechanical research that assessed <10 cases. In addition, publications were excluded if, despite fulfilling the inclusion criteria, consensus on which complications were being reported could not be reached. Therefore, no statistical analyses were performed. We also excluded literature on open fracture because some articles did not differentiate between open and closed fractures. The postoperative infection rates for these two types of fracture are significantly different,7,9,11 therefore there might be small differences between incidence rates calculated in this study and the true incidence rates of complications.
The present review concludes that postoperative complications of calcaneus fracture may not be avoided completely. However, the incidence rates can be reduced if the timing of surgery, the choice of the surgical approach, the anatomical reduction of the fracture and the perioperative management are appropriate. Early diagnosis of complications and suitable treatment also help to achieve satisfactory outcomes.
Footnotes
Declaration of conflicting interest
The authors declare that there are no conflicts of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.