Calcaneal fractures, often a result of traumatic incidents such as falls from height or motor vehicle accidents, present a significant challenge to orthopedic surgeons. These fractures are notorious for their complexity due to the calcaneus’s role in the foot’s structural integrity and the intricacy of adjacent soft tissues. With the continuous evolution of treatment modalities, a case reported by Macdonald et al. in the Ulster Medical Journal (2018;87(3):201–202) has shed light on a particularly difficult scenario where a calcaneus fracture was complicated by an interposed Flexor Hallucis Longus (FHL) tendon. The authors provided a surgical tip to aid tendon reduction, which has implications for current practices and patient outcomes.
DOI: The original article on which this news piece is based can be found through its DOI: 10.1039/UMJ.2018.87
The Case That Brought Attention to a Surgical Nuance
The article by Macdonald et al. describes a striking case of an adult male patient who suffered a calcaneus fracture with an interposed FHL tendon – a situation that adds layers of complication to an already complex fracture type. The surgical team implemented an innovative tip that involved using a “MacDonald Dissector” to facilitate the reduction of the displaced FHL tendon, thus allowing for proper alignment and stabilization of the fracture.
This surgical technique provides a specialized approach to a problem that might otherwise result in suboptimal outcomes due to the difficulty in repositioning the tendon. The efficacy of this technique is a significant point of interest within the orthopedic community, as it can guide future treatments for similar complex cases.
The Impact of Calcaneal Fractures and the Importance of Optimal Management
Calcaneal fractures account for approximately 2% of all fractures but up to 60% of all tarsal bone fractures, making proper management crucial for maintaining foot function and quality of life. While non-displaced fractures can be managed conservatively, displaced intra-articular fractures often require surgical intervention. Nonetheless, the approach to treatment remains a subject of debate.
Five critical references that delve into surgical and conservative interventions for calcaneal fractures include:
1. Bruce J, Sutherland A. Surgical versus conservative interventions for displaced intra-articular calcaneal fractures. Cochrane Database of Systematic Reviews. 2013. [DOI: 10.1002/14651858.CD008628]
2. Griffin D et al. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomized controlled trial. BMJ. 2014; 349:g4483. [DOI: 10.1136/bmj.g4483]
3. Schepers T et al. Current concepts in the treatment of intra-articular calcaneal fractures: results of a nationwide survey. International Orthopaedics. 2008;32(5):711–715. [DOI: 10.1007/s00264-007-0397-8]
4. Gougoulias N et al. Management of calcaneal fractures: systematic review of randomized trials. British Medical Bulletin. 2009;92(1):153–167. [DOI: 10.1093/bmb/ldp033]
5. Jiang N et al. Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base. International Orthopaedics. 2012;36(8):1615–1622. [DOI: 10.1007/s00264-012-1560-z]
The Debate: Surgical Vs. Non-Surgical Intervention
Though historical evidence tended to favor conservative management for these fractures, newer studies, such as the 2014 work by Griffin et al., suggest that surgical treatment could lead to increased patient satisfaction and better anatomical restoration. The meta-analysis by Jiang and colleagues further supports the preference for surgical intervention in specific case types, but stresses that the decision should be tailored to individual patient factors and the surgeon’s expertise.
The Present and Future of Calcaneal Fracture Management
Present-day management of calcaneal fractures involves a myriad of factors, such as the patient’s age, activity level, comorbid conditions, as well as the specific fracture type and its relation to the subtalar joint. In light of case such as the one presented by Macdonald et al., there is an emphasis on not only restoring bony anatomy but also ensuring the integrity and proper position of soft tissue structures. This highlights the future direction of treating calcaneal fractures with a more holistic approach.
Keywords
1. Calcaneal Fracture Surgery
2. Flexor Hallucis Longus Tendon Injury
3. Intra-Articular Calcaneus Fracture
4. Surgical Management of Foot Trauma
5. Operative Treatment of Heel Fracture
Conclusion
The complex nature of calcaneal fractures has stimulated a wealth of research and debate on their best-practice management. The case reported by Macdonald et al. has reinforced the importance of considering soft tissue involvement in the surgical intervention of these injuries. The inclusion of their surgical tip in the literature serves as a guide for future cases, potentially improving surgical outcomes for patients with similar complexities.
As the field of orthopedic surgery progresses, the incorporation of such specialized techniques, supported by evidence-based practices outlined in sources such as the Cochrane Review and BMJ, will continue to refine the approach to these challenging injuries and improve patient recovery and satisfaction.
While there is no one-size-fits-all answer for treating calcaneal fractures, it is the thoughtful consideration of each individual case, the meticulous attention to detail during the surgery, and the surgeon’s dexterity, as exemplified by Macdonald et al., that will ultimately lead to the best outcomes for patients.