Staged Management of Severely Displaced Calcaneal Fractures With Transarticular Pinning: A Damage Control Strategy

Abstract

Background: Severely displaced calcaneal fractures can result in considerable morphology derangement and may be accompanied by soft tissue compromise. Delayed operative restoration of the calcaneal morphology may result in acute retensioning of the damaged soft tissue with associated wound-related complications. In this study, we describe a staged treatment of displaced intra-articular calcaneal fractures that uses temporary transarticular Kirschner wire (K-wire) fixation and staged conversion to definite fixation. Methods: We identified all of the patients who were treated at our institution for calcaneal fractures between 2015 and 2019. A total of 17 patients with 20 calcaneal fractures were selectively treated with 2-stage management. Temporary transarticular K-wire fixation was performed 24 hours after the injury to restore calcaneal morphology and the surrounding soft tissue. After the soft tissue was considered safe, delayed open reduction and internal fixation was performed. The time to definite surgery, radiographic alignment, wound complications, time to radiographic union, and hindfoot American Orthopaedic Foot & Ankle Society (AOFAS) scores were recorded. Results: The average follow-up period was 17 months (range, 12-43). The average Böhler angle increased from a mean of −22 degrees (range, −109 to 25) to 25 degrees (range, 0 to 47) after temporary transarticular K-wire fixation. The mean time from temporary pinning to conversion to definite internal fixation was 20 (range, 10-32) days. There were no immediate postoperative complications. The average time to radiographic union was 13.7 (range, 10-16) weeks. The mean AOFAS score was 87 (range, 55-100). No infections or wound complications were reported during the follow-up period. Conclusion: Temporary transarticular pinning for staged calcaneal fracture treatment is safe and effective in restoring the calcaneal morphology. This novel and relatively simple method may facilitate delayed operation and decrease wound-related complications. Level of Evidence: Level IV, retrospective case series.

Response to “Letter Regarding: Staged Management of Severely Displaced Calcaneal Fractures With Transarticular Pinning: A Damage Control Strategy”

“…4 We believe that the staged approach as a concept of damage control surgery can be a safe and effective strategic option for complicated fractures, such as polytrauma and open fractures. 3 We agree that our protocol may increase some costs. Good results were also reported in staged ORIF with the use of an external fixator.…”

“…We appreciate Dr. Kwon and Dr. Ingall's great interest in our study of the staged treatment of calcaneal fracture, 3 and we welcome the opportunity to respond to their concerns. Our response would be helpful for readers to decide whether to apply the treatment protocol.…”

Comparison of temporary external and percutaneous k-wire fixations for treatment of ankle fracture–dislocations

“…They stated that injuries to the joint resulting from high-energy intra-articular impacts have a greater long-term effect. The transarticular K-wire has also been shown to provide favorable results and fewer treatment-related complications in the treatment of calcaneal fractures [42,43]. Therefore, we are justi ed in believing posttraumatic osteoarthritis is less relevant and more likely to be associated with initial fracture-dislocations.…”

A Staged Protocol for Treatment of High-Energy Tongue-Type Calcaneus Fractures: Surgical Technique and Case Series

“…1,2 Urgent surgical intervention under these circumstances may be warranted, but no consensus exists on the ideal management of these injuries in the acute setting, let alone how to manage these injuries definitively. 1,3–5…”

“…1,2 Urgent surgical intervention under these circumstances may be warranted, but no consensus exists on the ideal management of these injuries in the acute setting, let alone how to manage these injuries definitively. 1,[3][4][5] Although there is evidence supporting percutaneous management of tongue-type calcaneus fractures, there has been little focus on initial management of the soft tissue envelope if definitive treatment and reconstruction through a direct reduction of the articular surface is planned. Timing to surgery remains controversial for treatment of calcaneus fractures, which historically have contended with wound complications.…”