The main indication for this type of surgery is a displaced fracture of the heel bone (calcaneus fracture). A fractured calcaneus treated surgically with anatomical reduction of the fracture fragments (returning to near their pre-fracture position) that heals with no infection, no wound healing problems, and no local nerve injury will yield an optimal result. However, not all patients with calcaneal fractures are candidates for surgery. For many patients the risk of a serious complication such as a deep infection may out weight the potential benefits of surgery. It is often the judgement of the surgeon (after discussion with the patient) to determine if the patient is likely to do better with surgery than non-operative treatment.
The goal of this surgery is to reconstruct the bones back to their original position prior to sugery. This challenging endevour is equivalent to putting a broken egg shell back together – with many fragments that all need to be systematically reduced. Therefore fixing a fractured calcaneus optimally requires a surgeon with a lot of experience and expertise.
During surgery the patient is usually positioned on his or her side. The incision is made on the outside (lateral) of the foot. For most major calcaneal fractures an “L”shaped incision is made. It is important that an L shaped incision is made instead of an oblique incision; otherwise, there may be a corner of tissue lacking blood supply that is at high risk of necrosing (losing blood supply). The soft-tissue covering the outside of the heel bone is gently peeled off the bone and the nearby tendons on the outside of the foot (peroneal tendons) are retracted. This allows the calcaneus and the subtalar joint (the joint below the ankle) to be exposed.
Once this area has been exposed the process of systematically reassembling the calcaneus is started. There are usually two primary fragments of the fractured calcaneus and these fragments are realigned first and provisionally fixed with wires to hold them in that position. The joint surface is then reconstructed by systematically repositioning all of the other fracture fragments. These fragments are also provisionally fixed with wires until the entire calcaneus is rebuilt. In some cases, the joint in front of the calcaneous (calcaneal-cuboid joint) will also need to be fixed. Once the calcaneous is in an anatomically acceptable position, the provisionally fixed wires are sequentially removed and replaced with a plate or a series of screws (Figure 1A and 1B).
Figure 1A: Fractured Calcaneus
Figure 1B: Fixed Calcaneal Fracture
Once the calcaneal fracture has been reconstructed (put back together) it is then critical to perform a meticulous closure of the wound. The reason for a meticulous closure is because any breakdown of the wound will increase the risk of a significant post-operative infection.
In cases of extensive cartilage damage, the surgeon may recommend performing a primary subtalar fusion.
0-2 weeks Post Surgery
The foot is immobilized and elevated, while taking prescribed pain medication.
2-10 (or 12) weeks Post-Surgery
At the 2 week mark, the sutures are removed and the patient is placed in a cast boot. This boot may be removed a couple times per day to allow the patient to perform gentle hindoot range of motion exercises to increase the hindfoot motion. The extent of the bone healing process is longer than typical fractures because the calcaneus bears all the weight therefore, many patients with significant calcaneal fractures need to be non-weight bearing for 8-12 weeks after surgery. Once the fracture has healed adequately the patient may start weight bearing in a cast boot and eventually transition into a stiff-soled shoe.
Potential General Complications
Potential Specific Complications
Wound Healing Problems: Although this is usually a general complication for most procedures wound healing complications are particularly concerning following calcaneral fracture surgery. The area around the outside of the heel has relatively thin skin and soft-tissue coverage and an often tenuous blood supply. This can make wound healing problems more likely following calcaneal fracture surgery, and potentially more severe if they do develop. Wound healing problems are increased significantly for smokers and diabetics.
Infection: Infections can create a major problem if they occur following a calcaneal fracture. As a result of the limited soft-tissue covering the outside of the heel it is not uncommon for a superficial wound infection to spread down to the underlying bone and become chronic. The source of an infection is often inadequate wound healing.
Sural Nerve Injury: Injury to the nerve on the outside of the heel (sural nerve) can occur during calcaneal fracture surgery. Nerve injury can occur due to retraction, direct injury, or from scarring during the recovery process. If the sural nerve nerve is injured or cut, the patient could end up with numbness or pain along the path of the nerve.
Subtalar Arthritis: Painful subtalar arthritis and stiffness of the hindfoot is common following calacneal fracture surgery. This occurs not because of the surgery but because of the injury itself.
Painful Hardware: Pain may be associated with the screws and plates that areused to secure the bones. About 10-20% of people will need to undergoremoval of the screws due to discomfort, once the bones have healed.
Edited July 14th, 2009