Late Treatment of Displaced Intra-articular Calcaneus Fractures: When is Late too Late?

Surgery for DIACFs within 7 days of injury by a lateral extensile approach is associated with higher wound complication rates.8 This time interval allows for resolution of soft tissue swelling following trauma.In more severe injuries this will allow for fracture blisters or fracture-related hematoma to improve.After 2 weeks fibrosis begins to occur along the fracture lines making reduction technically more difficult.Additionally, with the restoration of calcaneal height at the time of reconstruction wound closure may become increasingly difficult as time passes due to contracture of the soft tissue envelope potentially leading to an increased rate of wound healing problems and infection.9,10 Why Should Late Surgical Management for Displaced Fractures be Considered?Surgical management of DIACFs results in improved outcomes in operative cases where the normal Bohler's angle is recreated and the articular surface reduction is within 2 mm.11,12 Buckley et al. found significantly better results in patients treated surgically who had joint reduction within 2 mm and a higher individual Bohler's angle.12 Agren and colleagues in a post hoc analysis of their randomized clinical trial observed higher postoperative Bohler's angle, and articular surface reduction leading to superior results in patients with operative treatment.12,13 A recent long-term evaluation of a large series of calcaneus fractures observed restoration of Bohler's angle to within 5 degrees of the unaffected side to be a IntroductIonCalcaneus fractures are rare but account for roughly 60% of tarsal bone fractures.1 The anatomy of the hindfoot is complex, increasing the difficulty of fracture management.The calcaneus is an odd-shaped bone with multiple articular facets and has a very unforgiving soft tissue envelope making appropriate surgical intervention time-sensitive.Certain surgical patterns including beak type, fracture-dislocation, and open fractures of the calcaneus require prompt surgical management.[2][3][4] Surgery, if performed, should ideally be done when the soft tissues have recovered and the fracture fragments are still mobile.The management of calcaneus fracture in delayed presentation requires technical skill and a surgeon experienced with both acute fracture management skills as well as arthrodesis and osteotomy techniques.The goal of operative treatment of displaced intra-articular calcaneus fractures (DIACFs) is to restore calcaneal height, axial alignment, and anatomically reduce the articular surface.This is also true in the management of late presenting fractures, but successfully doing so becomes more and more difficult with time.