Primary Subtalar Arthrodesis Versus Late Subtalar Arthrodesis in Sanders Type IV Calcaneal Fractures
Condition: Calcaneus Fracture
MeSH terms: Fractures, Bone
Study type: Interventional

Summary: 
      Fracture calcaneus accounts for up to 2% of all fractures. 75% of calcaneal fractures are
      displaced intra-articular fractures and historically have been associated with poor
      functional outcomes.

      When the talus applies an axial loading to the posterior facet, shear forces result in a
      primary fracture line between medial (sustentaculum tali) and lateral part of the calcaneus.
      As the axial force continues, a secondary fracture line will develop. According to the
      relation of the secondary fracture line's exit to insertion of tendo-achilis Essex-Lopresti
      classified that into two types joint depression and tongue.

      Numerous classifications exist in the literature but that by Sanders is the most prevalent
      and best suited for clinical practice and for research purposes.

      Sanders in his clinical trials found that as the number of articular fragments- based on
      axial and coronal CT scan cuts with the widest undersurface of the posterior facet of the
      talus- increase, the results and prognosis worsen.

      Up to 73% in the sanders type IV fractures eventually leads to subtalar fusion to manage
      post-traumatic subtalar arthritis. They are 5.5 times more likely to require subtalar
      arthrodesis than Sanders II fractures. Second surgeries increase the cost of management and
      delay the return of level of function for the patient.

      Some authors advocate that the fractures with a higher Sanders classification demonstrated no
      difference between operative and non-operative treatment. However, careful stratification of
      the patients may show better outcomes after surgical intervention in some groups.

      There is no consensus about how to manage calcaneal fractures but we can divide management
      into four broad categories: Non-operative, Open reduction and internal fixation, Minimally
      invasive reduction and fixation and finally Primary ORIF and subtalar arthrodesis.

      Our trial was conducted to add to the current evidence and our main questions are: does
      initial reduction and fixation of comminuted displaced intra-articular Sanders type IV
      calcaneal fractures matter in subtalar fusion?
    

Detailed description: 
      Randomization: patients presented to clinic or emergency room with recent (30 days or less)
      Sanders type IV intra-articular calcaneal fractures will be included in group A. Patients
      referred to our clinic (from other surgeons or hospitals) with old (more than three months)
      Sanders type IV intra-articular calcaneal fractures will form group B.

      Group A: open reduction and internal fixation plus primary subtalar arthrodesis.

      Group B: conservative management for at least three months then calcaneoplasty and late
      subtalar arthrodesis.

      Ethical Considerations: Will be followed by obtaining the hospital Research Ethics Committee
      approval and written informed consents from the patients.

      Intervention:

      All patients were subjected to the same initial treatment with below knee slab, limb
      elevation and analgesics.

      Patient in group A will be scheduled to surgery after resolution of the edema and appearance
      of wrinkle sign.

      They will be anesthetized and tourniquet will be applied over the thigh. Lateral position and
      lateral extensile approach will be used. A full flap will be developed by subperiosteal
      dissection with protection of sural nerve and peroneal tendons. Three k-wires will be
      inserted in fibula, lateral surface of talus and cuboid bones as retractors.

      A 4 mm schanz will be inserted in the calcaneal tuberosity from lateral side to control varus
      and to restore calcaneal height. Lateral wall of the calcaneus will be lifted keeping it
      attached inferiorly. Articular surfaces of inferior surface of the talus and posterior facet
      of the calcaneus will be debrided thoroughly and drilled by 2 mm k-wire. tricortical iliac
      bone autograft will be inserted the subtalar joint. A lateral nonlocked plate will be applied
      to reduce the lateral wall blow out and broadening then fixation by two cannulated partially
      threaded 7.3 screws from the calcaneal tuberosity to the talus. We will check position by
      fluoroscopy then closure in two layers (subcutaneous and skin) after homeostasis. Below knee
      slab will be applied and non-weight bearing for six weeks.

      Group B patients will be assessed upon 1st clinic visit. After at least three months patients
      will be scheduled for subtalar arthrodesis. A new preoperative ankle CT scan will be done.

      Patients will be anesthetized and tourniquet will be applied over the thigh. Lateral position
      and lateral extensile approach will be used. A full flap will be developed by subperiosteal
      dissection with protection of sural nerve and peroneal tendons. Three k-wires will be
      inserted in fibula, lateral surface of talus and cuboid bones as retractors.

      Lateral wall and plantar exostosis will be resected. Articular surfaces of inferior surface
      of the talus and posterior facet of the calcaneus will be debrided thoroughly and drilled by
      2 mm k-wire. Hind foot deformity (mostly varus) will be corrected through the subtalar joint
      manually and checked clinically. Loss of calcaneal height will be corrected by tricortical
      iliac bone autograft to distract the subtalar joint then fixation by two cannulated partially
      threaded 7.3 screws from the calcaneal tuberosity to the talus. We will check position by
      fluoroscopy then closure in two layers (subcutaneous and skin) after homeostasis. Below knee
      slab will be applied and non-weight bearing for six weeks.

      Post operatively, both groups will be followed after intervention every two weeks for two
      months then every three months for one year. Outcomes will be assessed using questionnaires
      in our clinic at six months and one-year visits.
    

Intervention name(s): open reduction and internal fixation plus primary subtalar arthrodesis; conservative management then calcaneoplasty and subtalar arthrodesis.
Intervention type(s): Procedure; Procedure
Intervention description(s): they will be scheduled to surgery after resolution of the edema and appearance of wrinkle sign. Lateral position and lateral extensile approach will be used. A 4 mm schanz will be inserted in the calcaneal tuberosity from lateral side to control varus and to restore calcaneal height. Lateral wall of the calcaneus will be lifted keeping it attached inferiorly. Articular surfaces of inferior surface of the talus and posterior facet of the calcaneus will be debrided thoroughly and drilled by 2 mm k-wire. tricortical iliac bone autograft will be inserted the subtalar joint. A lateral nonlocked plate will be applied to reduce the lateral wall blow out and broadening then fixation by two cannulated partially threaded 7.3 screws from the calcaneal tuberosity to the talus. We will check position by fluoroscopy then closure in two layers (subcutaneous and skin) after homeostasis. Below knee slab will be applied and non-weight bearing for six weeks.; they will be assessed upon 1st clinic visit. After at least three months patients will be scheduled for subtalar arthrodesis. A new preoperative ankle CT scan will be done. Lateral position and lateral extensile approach will be used. Lateral wall and plantar exostosis will be resected. Articular surfaces of inferior surface of the talus and posterior facet of the calcaneus will be debrided thoroughly and drilled by 2 mm k-wire. Hind foot deformity (mostly varus) will be corrected through the subtalar joint manually and checked clinically. Loss of calcaneal height will be corrected by tricortical iliac bone autograft to distract the subtalar joint then fixation by two cannulated partially threaded 7.3 screws from the calcaneal tuberosity to the talus. We will check position by fluoroscopy then closure in two layers (subcutaneous and skin) after homeostasis. Below knee slab will be applied and non-weight bearing for six weeks.
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Primary subtalar arthrodesis; Late subtalar fusion