What are the treatment options for a comminuted bilateral calcaneus fracture?

Treatment Options for Comminuted Bilateral Calcaneus Fractures

The optimal treatment for comminuted bilateral calcaneus fractures involves surgical management with open reduction and internal fixation (ORIF) using a calcaneal locking compression plate (LCP) for Sanders type II and III fractures, while minimally invasive techniques or primary subtalar fusion may be preferred for Sanders type IV fractures to reduce wound complications.

Initial Assessment and Imaging

• Standing (weight-bearing) radiographs including anteroposterior, medial oblique, and lateral views are preferred for initial assessment 1
• CT scans are essential for:
  • Accurate diagnosis and classification (Sanders system)
  • Preoperative planning
  • Determining appropriate surgical approach 2, 3

Treatment Algorithm Based on Fracture Classification

Sanders Type II and III Fractures

1. Open Reduction and Internal Fixation (ORIF)
   • Extended lateral approach with calcaneal LCP is the standard treatment 2, 3
   • Advantages:
     • Allows direct visualization of fracture
     • Enables accurate reduction of subtalar and calcaneocuboid joints
     • Provides stable internal fixation for early rehabilitation 3
   • Timing: Surgery should be performed after swelling subsides (typically 7-14 days) unless open fracture or compartment syndrome is present 3

Sanders Type IV Fractures

1. Minimally Invasive Techniques
   • Percutaneous fixation with external fixator and/or screws 4
   • Primary subtalar fusion using minimally invasive surgery (MIS) 5
   • Advantages:
     • Reduced wound complications
     • Preservation of soft tissue
     • Faster recovery 5, 4

Open Fractures

1. Staged Approach
   • Urgent debridement and temporary external fixation
   • Delayed definitive fixation after soft tissue healing 3, 6
   • Early soft tissue coverage with pedicled or free flaps if needed 6

Specific Considerations for Bilateral Fractures

• Higher complication rates compared to unilateral fractures 2
• More challenging rehabilitation process
• Staged surgical approach (operating on one side at a time) may be preferred to reduce perioperative risks 2
• Careful patient selection is crucial as bilateral cases show less satisfactory outcomes 2, 3

Postoperative Management

• Begin passive rehabilitation on first postoperative day 3
• Non-weight bearing for approximately 3 months until radiographic evidence of healing 3
• Regular follow-up at 6 weeks, 3 months, 6 months, and 12 months 3

Potential Complications

• Wound healing problems (higher in bilateral cases) 2
• Infection (superficial and deep)
• Malunion or nonunion
• Post-traumatic arthritis
• Chronic pain (approximately 20% of patients) 1

Pitfalls to Avoid

• Delaying surgery for open fractures or compartment syndrome
• Inadequate reduction of articular surfaces
• Failure to restore calcaneal height, width, and axis
• Premature weight-bearing before radiographic healing
• Overlooking atypical fracture patterns like sustentacular fractures 6

Special Considerations

• Contraindications for ORIF include:
  • Age over 60 years
  • Poor patient cooperation
  • Smoking
  • Peripheral vascular disease
  • Skin infections 3
• Bone grafting is generally not necessary for most calcaneal fractures 3, 6

The treatment of bilateral comminuted calcaneus fractures requires careful planning and execution, with surgical approach tailored to fracture classification and patient factors. While ORIF with calcaneal LCP remains the standard for Sanders II and III fractures, minimally invasive techniques may be preferred for Sanders IV fractures to reduce wound complications, particularly in bilateral cases where complication rates are significantly higher.