Calcaneus Fractures: Long-term Outcomes - What Can Patients Expect?

Sagar J. Desai, M.D., FRCSC
Clinical Fellow, Foot and Ankle Reconstruction
University of Toronto

Timothy R. Daniels, M.D., FRCSC
Head, Division of Orthopaedic Surgery, St. Michael's Hospital
Associate Professor, University of Toronto
Head, Foot and Ankle Program
Toronto, ON

Historically, displaced intra-articular calcaneal fractures are associated with a prolonged recovery with a variable prognosis. Whether to treat operatively or non-operatively has been discussed; the purpose of this section is to assess long-term outcomes.

The long-term sequelae from all calcaneal fractures, regardless of treatment, include subtalar and/or calcaneocuboid arthrosis, sequelae from compartment syndrome (claw toes) and chronic regional pain syndrome. Long-term complications related to, but not specific for, non-operative treatment include: malunion, a broadened heel, and lateral and/or anterior ankle impingement, and osteomyelitis in open fractures. Complications related to, but not specific for, operative treatment include: chronic osteomyelitis, symptomatic hardware, cutaneous nerve injury, and major wound healing complications requiring grafting (i.e. split thickness skin graft and/or free tissue flap).

Eleven clinical studies have reported long-term outcomes of intra-articular calcaneal fractures with an average follow-up of five years1-11. The largest study had an average follow-up of 12.8 years in 73 patients (81 fractures)10, and the smallest study was a review of 17 children at a mean of 16.8 years after injury3. Drawing any firm conclusions from these clinical studies is difficult given the variation in methodology, large number of patients lost to follow-up, inconsistent radiographic follow-up, and the utilization of different outcome scores.

Two of the larger studies found a correlation between severity of the injury and outcome. In a retrospective review, Potter and Nunley10 found that patients with calcaneal fractures resulting from a high-energy motor-vehicle accident trended towards a poorer outcome when compared to those injured from a fall; all were treated operatively. Rammelt and colleagues11 found a correlation between poorer outcome and severity of injury, work-related injuries and bilateral fractures. The Sanders type III and IV fractures had the worst outcomes. All patients in the study were treated operatively.

Post-traumatic subtalar arthrosis is one of the most common long-term sequelae of calcaneal fractures. Allmacher et al.1 identified the presence of subtalar arthrosis on CT scan to be a predictor of lower average outcome scores after non-operative treatment of a displaced intra-articular calcaneal fracture, and its presence was associated with an increased risk of deteriorating function in the second decade after injury. In long-term follow-up studies, the incidence of subtalar arthrodesis ranges from 0%4,6 to 11%7, 15%5, and 21%9. In a review of 70 patients, Paul et al.9 identified a strong correlation between restoration with operative intervention or maintenance with non-operative management of Bohler's Angle (BA) and subtalar arthrosis and/or fusion. If an open reduction was performed and BA was not restored, a poorer outcome was noted. In shorter-term studies, the incidence of subtalar arthrosis leading to subtalar arthrodesis ranged from 2-17%12-14. Csizy et al12 found that 3% of surgically-treated patients required late subtalar fusion, whereas 17% of non-surgically-treated patients required fusion. Displacement of as little as 2mm can alter contact pressures on the subtalar joint, which may predispose the joint to arthrosis15. It is estimated that initial non-operative care is five to six times more likely to lead to a need for late arthrodesis12,16. Subtalar arthrosis can lead to diminished function and chronic pain. Unfortunately, none of the long-term studies helped determine if the incidence of subtalar arthrodesis is influenced by the method of treatment. Interestingly, the incidence of subtalar fusion tends to be higher in clinical studies with short-term follow-up, compared to those with long-term follow-up. This may be a reflection of missed outcome events for those patients who were lost to long-term follow-up. If arthrodesis is ultimately required, multiple studies have shown that late subtalar arthrodesis can be a successful treatment17-19. Patients who were initially treated operatively tend to have better functional scores after subtalar arthrodesis than patients treated non-operatively before undergoing arthrodesis20.

Long-term complications from calcaneal fractures can lead to disability and decreased work capability. Calcaneal fractures occur most commonly in people engaged in medium and heavy labour. Whether treated operatively or non-operatively, these patients take longer to return to work and have greater decreases in work capability than patients with more sedentary jobs. Heavy labourers return to work 75% of the time16, often at a diminished work level21. Other predictors of decreased work capability in patients with calcaneal fractures include male gender, non-operative treatment, and bilateral fractures21.

Calcaneal fractures can result in long-term morbidity, mainly from calcaneal malunion and subtalar arthrosis. Surgical techniques for managing these complications are evolving and have demonstrated good clinical results; however, to date there is no Level I or II evidence that long-term surgical outcomes are superior to non-operative management. Regardless of treatment, many patients continue to have diminished function and chronic pain.

References

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