Jason St. John, DPM, MS

Fellow, University of Pittsburgh Medical Center

Lower Extremity Limb Salvage/Trauma Fellowship

Primary Subtalar Joint Arthrodesis in the

Treatment of Calcaneal Fractures

• No conflicts of interest

Conflict of Interest

• Review initial management

• Review common complications

• Discuss the role of subtalar fusion in management of calcaneal fractures

• Discuss outcomes

• Review common fixation techniques for primary subtalar joint arthrodesis

Purpose

• 2.6% of all bodily fractures

• 60% tarsal injuries

• 75% fall from a height

– Average 14 feet

• 70% have associated injuries

– 10-20% Spinal compression fracture

• 75% intra-articular in adults

Incidence

• Multiple initial management strategies

– Non-op, lateral extensile, mini open, sinus tarsi, percutaneous, primary arthrodesis

• Factors to consider:

– Degree of injury/comminution

– Skin condition/blister management

– Timing of surgery/edema control

– Concomitant injuries

– Medical comorbidities

• Goals:

– Restore articular surface

– Regain height of the posterior facet

– No varus

– Reduce width

Initial Management

• Complications occur in both operative and non-operative management

– Wound healing complications

– Surgical site infection/osteomyelitis

– DVT/PE

– Malposition/malreduction

– Compartment syndrome

– Painful hardware

– Nerve injury

– Peroneal tendon issues

– CRPS

– Need for shoe wear modifications

– Anterior ankle impingement

– Development of arthritis/need for arthrodesis

• Typically associated with STJ, can also be CC

Complications in Calcaneal Fractures

• Initial management strategy vs treatment for late complications

• Used in the acute setting to manage fractures with severe comminution and/or cartilage

damage

– Sanders IV

• Late used to manage post traumatic arthritis, ankle impingement, correct residual

deformity

– Often distraction arthrodesis

• Delayed vs initial fusion?

Role of Subtalar Arthrodesis

• Often discussed in relation to Sanders Type IV fractures

• Type IV fractures with poor outcomes regardless of surgeon experience– Sanders, Clinical Ortho. and Related Research, 1993

• High rate of post traumatic arthritis in intra-articular calcaneal fractures, highest rate is in

Sanders Type IV

• Allows for ORIF and fusion in one stage, eliminating need for return to OR for

management of post traumatic arthritis in patients with more severe injury

• Reasonably good reported outcomes in the literature

Why consider primary arthrodesis?

• Harris, Annals of Surgery, 1946

– Treatment of calcaneal fractures with distraction and arthrodesis of “subastragalar”

joint

– Necrosis of detached fragments and inability to completely restore articular surface

lead to significant disability

– 35 pts with 47 fractures—industrial and war injuries

• All but one returned to work at 6 months

• Dick, JBJS Br, 1953

– Recommended fusion if “significant distortion of the subtalar joint”

– Even though fracture can be reduced, “irreparable damage to the articular cartilage”

• All 10 patients returned to work at 6.5 months

• Hall, JBJS Br, 1960

– Used for patients with “gross depression or comminution”

– Reduction of deformity and arthrodesis with iliac crest graft

– 29 patients, 25 returned to work at 6.5 month average (93%)

Early Primary Arthrodesis

• 424 patients, 471 fractures– 44 ultimately required subtalar distraction arthrodesis 1-4 yrs after injury

– Compared those needing fusion with others

• Evaluated:– Bohler’s angle, Sanders classification, VAS, SF-36, oral analoque scale

• Bohler’s angle <0 deg 10x more likely to undergo fusion than >15 deg

• Sanders Type IV 5.5x more likely to undergo fusion than Sanders II– 46.5% of Sanders IV went on to late arthrodesis

• Workers compensation 3x more likely to undergo arthrodesis

• Non op 6x more likely

• 7 case series, 1 abstract reviewed

• 120 patients, 128 comminuted calcaneal fractures– Average f/u 28 months

• Average AOFAS score (7 studies) 77.4 (72.4-88)

• Paley score (1 study): 75% good to excellent outcome

• Return to work (4 studies): 75%-100% of patients

• “The primary arthrodesis for the treatment of Sander type-IV comminuted

displaced intra-articular calcaneal fractures provides overall good results

considering the severe nature of the injury.”

• Should consider primary arthrodesis in these patients.

• 31 patients, 31 fractures– Sanders Type IV

– Randomized to ORIF (17 patients) or ORIF with primary subtalar arthrodesis (14 patients)

– 26 patients for follow up (minimum 2 yrs)—13 from each group

• Evaluated using SF-36, Musculoskeletal Functional Assessment (MFA), AOFAS

Hindfoot scale, VAS– No statistical difference between the 2 groups in any outcome measure

• Collection stopped after 7 years for practicality, did not achieve the 66 patients

they initially calculated would be needed– Power calculation based on prior trial

• Patients with primary arthrodesis may heal faster and do not require additional

surgery later in time, therefore needs to be considered in this patient population– Healing based on time to weight bearing in this study: 10 wks ORIF, 6 wks ORIF + arthrodesis

• 17 patients, 17 fractures– Sanders Type IV; Avg follow up 34 months

• Evaluated radiographic outcomes, AOFAS ankle-hindfoot score

• Average AOFAS score: 78.4

• Average VAS: 1.9

• Statistically significant association between higher AOFAS scores and:– Increasing age, improved restoration of Bohler’s angle, improvement in restoration of the

talocalcaneal angle

• Outcomes of primary arthrodesis favorable, particularly when radiographic

relationships restored– Better reduction, better outcomes

• Address

– Height

– Varus

– Width

• Prepare joint surfaces

• Fixate

– Calcaneus

– STJ

Surgical Technique

14

• Full thickness classic exposure

vs sinus tarsi approach

• No touch technique

– K-wire in fibula and talus to retract

flap

• Reduce fracture fragments

• Temporary fixation of fracture

– Sometimes into talus

• Definitive fixation of fracture

Surgical Technique

15

Surgical Technique

16

Surgical Technique

17

• Prepare joint

• Leave enough room for STJ

fusion screws

– Need to plan fusion hardware

around fracture fixation hardware

• STJ fixation

• Fall off ladder

Surgical Technique – Case 1

18

Surgical Technique – Case 1

19

Surgical Technique – Case 1

20

Surgical Technique – Case 1

21

Surgical Technique – Case 2

22

Surgical Technique – Case 2

23

Surgical Technique – Case 2

24

Surgical Technique – Case 2

25

• Reasonable option for highly

comminuted fractures/fractures with

significant cartilage damage– Most commonly described in Sanders IV

• May have better outcomes if anatomy

restored prior to arthrodesis

• Allow room for arthrodesis hardware

when planning fixation

• May offer a method to reduce number of

surgeries and maintain good clinical

outcomes in highly comminuted

fractures

Conclusion

References

Buch BD, Myerson MS, Miller SD. Primary subtaler arthrodesis for the treatment of comminuted calcaneal fractures. Foot Ankle Int.

1996;17(2):61-70.

Buckley R, Leighton R, Sanders D, et al. Open reduction and internal fixation compared with ORIF and primary subtalar arthrodesis for

treatment of Sanders type IV calcaneal fractures: a randomized multicenter trial. J Orthop Trauma. 2014;28(10):577-83.

Csizy M, Buckley R, Tough S, et al. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop

Trauma. 2003;17(2):106-12.

Dick IL. Primary fusion of the posterior subtalar joint in the treatment of fractures of the calcaneum. J Bone Joint Surg Br. 1953;35-

B(3):375-80.

Hall MC, Pennal GF. Primary subtalar arthrodesis in the treatment of severe fractures of the calcaneum. J Bone Joint Surg Br.

1960;42-B:336-43.

Harris RI. Fractures of the os calcis; their treatment by tri-radiate traction and subastragalar fusion. Ann Surg. 1946;124(6):1082-1100.

Holm JL, Laxson SE, Schuberth JM. Primary subtalar joint arthrodesis for comminuted fractures of the calcaneus. J Foot Ankle Surg.

2015;54(1):61-5.

Huefner T, Thermann H, Geerling J, Pape HC, Pohlemann T. Primary subtalar arthrodesis of calcaneal fractures. Foot Ankle Int.

2001;22(1):9-14.

Potenza V, Caterini R, Farsetti P, Bisicchia S, Ippolito E. Primary subtalar arthrodesis for the treatment of comminuted intra-articular

calcaneal fractures. Injury. 2010;41(7):702-6.

Sanders R, Fortin P, Dipasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a

prognostic computed tomography scan classification. Clin Orthop Relat Res. 1993;(290):87-95.

Schepers T. The primary arthrodesis for severely comminuted intra-articular fractures of the calcaneus: a systematic review. Foot

Ankle Surg. 2012;18(2):84-8.