Calcaneus Fractures: Primary Fusion - Is There a Role?

Richard E. Buckley, M.D., FRSCS
Head, Orthopaedic Trauma Division
University of Calgary
Calgary, AB

In the early 90's, orthopaedic surgeons began to understand calcaneal fractures by using CT scans to investigate the morphology of the fracture. Roy Sanders had published his classic article about the CT-based classification of calcaneal fractures which was very important because the CT scan images reflect the amount of energy that has gone into the fracture and the ease of operative reduction.

Non-displaced calcaneal fractures (Sanders I) are usually treated non-operatively because they are minimally displaced or non-displaced and most patients do extremely well with benign management only. Sanders II fractures usually involve a single fracture line and are usually treated with either non-operative care in the very elderly or operative care (full open reduction or MIPO). They are easy to fix and results are positive in carefully selected patients (young patients, non-smokers, fracture dislocations, compliant self-employed individuals). Sanders III fractures are quite a bit more injurious to the calcaneus with more significant posterior facet disruption and are more difficult to reconstruct for the calcaneal surgeon. As in the Sanders II fractures, the Sanders III fractures can be best treated operatively in the right, carefully selected patient but can also be treated with minimally invasive surgery, especially where patient demographics (smokers, older patients, soft tissue compromise, diabetics) make full open reduction difficult. Lastly, the Sanders IV calcaneal fracture has been a real dilemma based on demographics (they are quite rare with no prospective studies in this area), and the severity and difficulty of presentation. Often the foot is badly injured; very swollen and operative decisions are difficult (Figure 1). A recent Canadian Orthopaedic Trauma Society study, which was a randomized trial comparing operative reduction versus operative reduction with primary fusion of the subtalar joint, was undertaken. This resulted in 31 fractures being randomized to the two arms of the study. Long-term follow-up (two to seven years) showed that there was no difference in long-term (two-year out) outcomes. They demonstrated no significant difference in the visual analog score, SF 36 score and American Association of Foot and Ankle Surgery score. (Abstract presented at Orthopaedic Trauma Association meeting Phoenix, AZ, Oct 12 2013 - Submitted for publication).

Figure 1: Sanders IV CT scan.

The decision for open reduction internal fixation versus primary fusion of a Sander's IV calcaneal fracture is a difficult one. Psychiatric patients or patients with very severe foot deformities would probably be best treated with primary fusion to establish good foot position, no valgus of the hindfoot and normal relationships of the ankle and hindfoot. Those patients who are compliant, and who could tolerate an initial attempt at ORIF are reasonable candidates for reduction. In the future, if the subtalar joint wears out, they would then be candidates for late secondary subtalar fusion. The initial treatment of a Sanders IV fracture with primary subtalar fusion is reasonable, however, because this avoids the possible need for two surgeries (Figures 2,3).

Figure 2: Sanders IV fracture fused at two yearsv(lateral view).

Figure 3: Sanders IV fracture fused at two years (axial view).

As in all calcaneal fractures, it is imperative that the calcaneal fracture surgeon avoid complications. Whichever surgical procedure or non-operative treatment will allow the patient to achieve the best long-term outcomes, without suffering complications, is usually the best treatment direction. This has been well-established with outcome studies. There has been a radical shift in thinking and treatment for calcaneal fractures such that we are now selecting the right operation for the right patient at the right time with the right surgeon.


  1. Open Reduction and Internal Fixation Compared With Open Reduction Internal Fixation with Primary Subtalar Fusion for Treatment of Sanders Type IV Calcaneal Fractures: A Randomized Multi Centre Clinical Centre Trial - Canadian Orthopaedic Trauma Society, Presented at Orthopaedic Trauma Association Meeting, Phoenix, AZ, Oct 12, 2013.