Standard radiographs of the ankle joint include antero-posterior with 20° internal rotation of the leg, so-called “mortise view,” and lateral views (Fig. 28.2). Standard radiographs of the foot include dorsoplantar (with 20° craniocaudal tilted X-ray tube for the Lisfranc joint and with 30° craniocaudal tilted X-ray tube for the Chopart joint), oblique and lateral views [4–6] (Fig 28.2). Load-bearing views for chronic conditions are recommended as many subtle injuries can only be appreciated under weight bearing [4, 6]. There should be generous use of computed tomography (CT) scans in any suspected fracture at the hindfoot or midfoot. CT scans also allow three-dimensional (3D) reconstructions, which are helpful for preoperative planning [7] (Fig 28.3). Magnetic resonance imaging (MRI) is useful for subacute and chronic conditions, especially tendon and ligament pathology, avascular necrosis, etc. [6]. Ultrasound and Technetium-99m (Tc) bone-scans may also be useful for investigation of painful conditions and for supplementing information provided by X-rays and CT scans.

Determination of the history of accident, inspection, palpation, control of motion, sensation, and perfusion of the foot are basic steps of the clinical investigation. Standard radiographs include anteroposterior and lateral views of the talus. The dorsoplantar view with 15° pronation and 75° cephalad tilted tube from the table top, so-called “Canale view,” reveals subtle varus malposition of the talar neck as well as the involvement of the talonavicular joint [14]. The Broden view with 45° internal rotation of the leg and a 40° caudally tilted tube demonstrates the lateral process and the subtalar joint. CT scanning in coronal and sagittal 1-mm sections is recommended for specific diagnosis, operative planning, and identification of additional injuries, which cannot be detected with conventional radiographs, for example, peripheral fractures, comminution, and subluxation.

Persistent pain after subtalar dislocation or lateral ligament injury of the ankle warrants further investigation by CT scanning to exclude peripheral fractures or MRI to exclude osteochondral fractures. MRI is not indicated in acute injuries, because of the bone marrow edema, but is useful for the evaluation of the vitality or revascularization of the talar dome post-fracture.

The rare undisplaced fractures of the talar body and neck (type A, Hawkins I, Marti II) may be treated in a non-weight-bearing, below-the-knee cast of the involved leg for 6–12 weeks [14]. However, a percutaneous screw transfixation allows early function after treatment and avoids a secondary displacement in such cases.

Conservative therapy of undisplaced fractures is associated with arthritis in 30 % of all cases [40], because a small amount of joint incongruency can cause significant weight redistribution between the joint facets [41]. Conservative treatment attempts for Hawkins II fractures have an unacceptably high rate of redislocations and unsatisfactory results [14]. Nonoperative treatment attempts for peripheral fractures, particularly lateral process fractures, often causes painful nonunion or malunion, which may require a subtalar arthrodesis [37, 42].

Osteochondral fractures of stage I and II (Berndt and Harty classification) can be subjected to a trial of conservative treatment [19, 43]. Stage I injury is subjected to functional therapy with limitation of sporting activity and a short duration of non-weight-bearing of the affected foot. Stage II injury requires immobilization in a cast or orthosis for 6 weeks.

The anteromedial approach for talar neck and anterior talar body fractures with protection of the blood supply of the posterior talar dome is via the deltoid ligament. An additional osteotomy of the medial malleolus for central fractures of the talar body may be added.

A bilateral approach is required for fracture dislocations, including comminuted fractures and all fractures with involvement of the subtalar joint (lateral process fractures). The lateral approach is performed either anterolaterally or with an oblique incision [55]. A posterolateral approach is useful for dorsally located talar body fractures and posterior process fractures. The posteromedial approach lateral to the posterior tibial neurovascular bundle is rarely required for fractures of the posteromedial tubercle or body. Visualization of the joint surfaces can be facilitated with a medial distractor [4].

The anatomical reduction of the talar axis as well as the joint surfaces is performed under direct visual control. The fragments are fixed temporarily with K-wires. Osteosynthesis with screws provides adequate stability for the most talar fracture types [61] (Fig. 28.7). The screw heads are countersunk near the joint surfaces.

Lag screws should be avoided to prevent shortening or varus malposition of the talar neck [47]. Mini-plate osteosynthesis and autologous cancellous bone grafting are required for large central comminution [55]. Titanium implants are recommended in order to facilitate MRIs in the postoperative period. Anatomical reconstruction is sometimes not possible for severely comminuted fractures. In such cases, the goal of treatment is reconstruction of the anatomical shape of the talus to facilitate secondary arthrodesis of the highly destroyed joint surface after temporary tibiometatarsal external fixation for 10 days [4].

General emergency principles are:

The preservation of the talus after copious lavage is indicated even in the rare case of total talar dislocation, “Luxatio tali totalis.” Any soft-tissue insertions to the talus should be carefully preserved as they may serve as blood supply for revascularization [62].

Talar head fractures may result from midtarsal (Chopart) fracture dislocations, therefore, additional fractures of the cuboid, navicular, or anterior calcaneal process as well as ligamentous instabilities have to be ruled out [63]. Displaced talar head fractures are reduced anatomically via an anteromedial approach. Depending on the fragment size, the fragments are fixed with 2.7- or 3.5-mm cortical screws, which are countersunk under the cartilage surface.

Fractures of the lateral process should be treated by open reduction via an Ollier approach and internal fixation with 2.0- to 2.7-mm screws. Comminuted lateral process fractures, small fragments, or old, overlooked lesions are excised [37, 64]. Posterior process fractures are reduced and internally fixed with screws via a posterior approach to avoid painful malunion or nonunion affecting the ankle and subtalar joints.

Surgical treatment for stage-III and IV osteochondral injuries according the Berndt and Harty [19] is indicated. Larger fragments >7 mm can be fixed open or arthroscopically with minifragment screws, absorbable pins, or fibrin glue [65, 66] (Fig. 28.8). Smaller fragments are excised.

Arthroscopic therapy with debridement, drilling of the subchondral bone, or microfracture and curettage is recommended for small and medium-sized lesions less than 3 cm² [67, 68]. Patients with extensive lesions, high functional demand, or failure after arthroscopic drilling and curettage can be treated with bone/cartilage autotransplantation (mosaicplasty, OATS = osteochondral autologous transplantation), extraction of chondrocytes from the patient, in vitro culture followed by transplantation back into the body defect that requires regeneration (ACT = autologous chondrocyte transfer; MACT = matrix associated chondrocyte transfer), or use of 3D porous materials to stimulate the in-growth of new tissue (AMIC = autologous matrix induced chondrocytogenesis) [69–72].

Reduction of a subtalar dislocation should be performed emergently, because persistent malposition endangers the perfusion of the skin as well as the talar body. Most medial dislocations can be reduced under general anesthesia with a flexed knee; the plantar flexed foot is pulled distally and is then dorsiflexed and pronated, and direct digital pressure on the dislocated talar head assists the reduction. The medial dislocation is rarely complicated by incarceration of the short toe extensors, requiring an open reduction via an Ollier or anterolateral approach. A talocalcaneal transfixation with K-wires for 6 weeks is required if instability persists after closed reduction.

For lateral subtalar dislocation, an assistant holds the forefoot and the heel, while the surgeon takes the lower leg with one hand, forces the calcaneus on his/her knees, and manipulates the talus head with his/her other hand [4]. This dislocation is often associated with an interposition at the posterior tibial or flexor digitorum longus tendon, which requires an open reduction via an Ollier approach.

Anteroposterior, dorsoplantar, and lateral weight-bearing radiographs of both ankles and feet as well as CT scans for preoperative analysis and planning.

MRI is useful for evaluation of the vascularization of the talus.

Anatomical reconstruction via corrective osteotomy preserving all three joints, if there is no arthritis, infection or total avascular necrosis with collapse of the talar dome [75]. Bilateral approach using anteromedial plus Ollier approach, followed by atraumatic handling of soft tissues is recommended. After reconstruction, the osteotomy in the previous fracture line is fixed with screws. Bony defects can be bone grafted.

A bilateral approach is used. Nonunion should be resected completely and the malalignment as well as the joint surfaces must be corrected. The perfusion of the adjacent bone can be enhanced by drilling. The defect from resection of the nonunion is filled with cancellous bone or corticocancellous block grafting with osteosynthesis using two or three compression screws.

This step begins with debridement of necrotic bone and correction of the axial deviation, followed by filling of the defect with cancellous bone or corticocancellous block graft. With osteonecrosis and collapse of the talar body, an additional subtalar or ankle arthrodesis is required after grafting the talar body (Fig. 28.9). With partial avascular necrosis, anatomic reconstruction and screw fixation is possible.

Complete avascular necrosis of the talus requires complete excision of the necrotic corpus, preserving the anteromedial facet joint and the talonavicular joint, if possible. Tibiocalcaneal arthrodesis with a sliding bone block from the anterior distal tibia edge, so-called Blair fusion, is needed for complete loss of the talar body [78]. Tibiocalcaneal fusion with retrograde nailing [79] has better biomechanical stability but leads to unphysiological loading of the distal tibia with an increased risk for stress fractures [80].

Treatment includes radical debridement, defect filling with antibiotic beads (e.g., gentamycin), tibiometatarsal transfixation with an fixateur externe, and planned revisions to eradicate the infection. After eradicating the infection, the defect is filled with bone graft. Loss of length after talectomy is prevented by anteromedial translation of the calcaneus [81]. Secondary lengthening procedures are possible.

An acute compartment syndrome, which occurs in 10 %, can be excluded with serial clinical examination and/or repeated measurement of the compartment pressure. Standard radiographs include axial and lateral views of the calcaneus supplemented by a dorsoplantar view of the foot. If an intra-articular fracture is suspected, axial and coronal CT scanning has to be carried out. This allows a three-dimensional analysis of fracture morphology, involvement of the joint facets, and precise surgical planning. The modern classification systems of calcaneus fractures are based on CT scans.

Lateral radiographs of the contralateral uninjured side are recommended for exact assessment of reduction [4] if surgery is indicated, since there can be individual differences in morphology, especially Böhler’s angle. Anteroposterior films of the ankle joint are obtained to see the amount of fibulocalcaneal abutment. Oblique views of the subtalar joint, the so-called Brodén view, can help to demonstrate the extent of subtalar joint involvement.

Conservative therapy is indicated for extra-articular fractures without significant malposition of the hindfoot (varus <5°, valgus <10°, shortening or enlargement <20 % of the other side), undisplaced intra-articular fractures (Sanders type I), as well as when there are contraindications to surgery [16]. The patient is restricted to bed rest for 3–4 days. The injured limb is elevated and ice is applied to the foot. To reduce soft-tissue swelling, the use of nonsteroidal antiinflammatory drugs may be helpful (e.g., ibuprofen 3 × 600 mg p.o./d in combination with pantozole 40 mg p.o./d). Encourage emptying of the venous plexus with venous pump training. Administering of low-molecular-weight heparin is mandatory.

The patient is mobilized with partial weight bearing of the injured leg for 3–6 weeks. Full weight bearing can be allowed after 6–12 weeks, depending on the bone quality and fracture anatomy. The goal is early mobilization of the patient. Physical therapy is directed towards regaining full range of motion in the ankle, subtalar, and Chopart joints early. Special footwear, for example, with a flexible arthrodesis boot (Variostabil), and full weight bearing may be allowed after 8–10 days.

General contraindications to surgery are severe neurovascular insufficiency, poorly controlled insulin-dependent diabetes mellitus, poor compliance, and severe systemic disorders with a poor overall prognosis or immune deficiency. Relative contraindications include age over 65 years, depending on the patient’s overall condition and functional demand. Local contraindication to surgery is critical soft tissue damage with high infection risk, such as, significant blistering, skin necrosis, ulceration, and advanced arterial or venous insufficiency.

All intra-articular fractures with joint displacement of more than 1 mm and extra-articular fractures with a hindfoot varus of more than 5°, hindfoot valgus of more than 10°, or considerable flattening, broadening, or shortening of the hindfoot should be treated operatively. Soft-tissue condition and associated injuries are crucial for timing of surgery. Emergency procedures are needed for open fractures and closed fractures with compartment syndrome or severe compromise of the soft tissues by fracture fragments.

Open fractures require initial debridement of the wound, which is typically situated medially, temporary closure with skin substitutes, minimally invasive fracture reduction and K-wire fixation supplemented by an external fixator. After 48–72 h, a second look with debridement is carried out and the type of soft-tissue coverage required is determined. A standard internal fixation is performed after soft-tissue consolidation, mostly within 10–12 days.

Monotraumatized patients with compartment syndrome should undergo release of the hematoma followed by a standard osteosynthesis. The majority of calcaneal fractures are accompanied by considerable soft-tissue compromise, representing Tscherne grade II closed soft-tissue damage [87].

Delayed osteosynthesis is preferred after the swelling has markedly decreased, usually within 10 days. Open reduction and internal fixation of intra-articular calcaneal fractures aims to restore the anatomical shape of the calcaneus, anatomically reconstruct all affected joint surfaces, and achieve stable osteosynthesis without joint transfixation so as to allow early active and passive movement (Fig. 28.16).

In polytraumatized patients with compartment syndrome of the foot, a classic dorsomedian dermatofasciotomy is carried out, releasing the skin, dorsal fascia, and distal extensor retinaculum, followed by external fixation [4]. The deep calcaneal compartment is released by a separate hindfoot incision similar to that used for a plantar fascia release [88].

Because of the critical soft-tissue condition, minimally invasive treatment options such as fluoroscopic and arthroscopically assisted fixation for selected fracture patterns have gained increased attention in recent years [89, 90]. Limited approaches and percutaneous osteosynthesis are employed with critical soft-tissue conditions, in polytraumatized patients, and in selected patients with contraindications to open surgery [91].

The patient is placed on the operating table in a supine position with a tourniquet on the thigh of the injured leg. A horizontal incision or a lazy-S incision in line with the skin creases, about 8–10 cm, is made exactly halfway between the tip of the medial malleolus and the sole. The subcutaneous plane and fascia are dissected. The next step is careful dissection and mobilization of the neurovascular bundle, which is marked and held away with a Penrose drain. The abductor hallucis longus muscle is retracted downward, whereas the flexor hallucis longus tendon is identified and left in place. The sustentacular fragment of the calcaneus is now visualized with preparation down to the periosteum.

A cancellous 6.5-mm Schwanz screw with a T-handle is introduced into the tuberosity via a stab incision. The tuberosity fragment can now be reduced by axial pull, away from the sustentacular fragment and the anterior process. If correct anatomical reconstruction of the medial wall is achieved, the reduction is fixed temporarily with 1.6–2.0 mm K-wires. Temporary transfixation of the joint may be necessary. Definitive fixation is achieved with a small anti-glide “cervical” H-plate and four 3.5-mm cortical screws, of which one should run into the anterior process fragment and two into the tuberosity fragment. Contour the H-plate according to the individual contour of the medial wall of the calcaneus to prevent any gliding of the fragments when tightening the screws.

A classical medial “McReynolds” [105] and a direct lateral approach are required for the calcaneal fracture-dislocation with lateral and proximal translation of the tuberosity fragment [103].

This is the standard approach that is most useful with displaced intra-articular calcaneus fractures that involve the posterior facet, which is fractured in 96 % of cases. The patient is placed on a radiolucent operating table in a lateral decubitus position on the noninjured side. Alternatively, the prone position is used. A tourniquet (200–300 mmHg) is placed on the thigh of the injured leg, the leg is draped free, and a sterile tape is applied to the toes. The tourniquet is used only for joint reconstruction in the absence of an additional acute compartment syndrome.

Skin incision is boomerang-shaped over the lateral aspect of the heel, running between the lateral malleolus and the posterior and inferior borders of the heel, respectively. The tip of the lateral malleolus and the fifth metatarsal base serve as landmarks for the incision. The subcutaneous layer is dissected in a strict vertical fashion down to bone. Care has to be taken to preserve the sural nerve as well as the lesser saphenous vein in the proximal incision. When extending the subcutaneous dissection distally to visualize the calcaneocuboid joint, the peroneal tendons are identified and mobilized within their sheaths, in order to prevent postoperative adhesions. They are gently held back with a blunt retractor. The calcaneus is progressively exposed epiperiosteally until the subtalar joint becomes visible. The distal retinaculum of the peroneal tendons and the fibulocalcaneal ligament are detached subperiosteally. A full-thickness cutaneous flap is developed, which can be retracted temporarily with K-wires introduced into the lateral process of the talus and the cuboid. Alternatively, sutures may be used. Use of sharp distractors is to be avoided.

When all fracture fragments are identified, the tuberosity fragment is mobilized with the Westhues maneuver. A 6.5-mm cancellous Schanz screw with a T-handle is introduced into the tuberosity after a stab incision. Under direct visualization of the subtalar joint, the handle is moved downward in order to bring the tuberosity fragment back to its correct position. At the same time, varus or valgus malalignment is corrected. The posterior facet is now reduced in a step-wise fashion from medial to lateral. Should the medial portion of the posterior facet be tilted laterally it must be reduced congruently to the inferior joint surface of the talus first and fixed with a 2.0 K-wire introduced from plantar into the talus. The depressed lateral portions of the posterior facet are elevated and fixed with 2.0 K-wires to the sustentaculum. If an intermediate fragment is present, the K-wires are drilled through the medial wall and pulled back to the lateral edge of this fragment. Then the lateral fragment is reduced onto the intermediate fragment. K-wires are drilled back to emerge laterally.

The K-wires are introduced 5 mm below the joint surface and are directed 10° superiorly towards the talus and 15° anteriorly towards the midfoot. The resulting articular block is then fixed to the initially mobilized tuberosity fragment. The whole posterior fragment can now be brought into alignment with the anterior process fragment to reconstruct the crucial angle. With extremely unstable fractures, temporary fixation is extended to the talus and cuboid.

Should a fifth fragment be present, the so-called anterior facet fragment, the calcaneocuboid joint has to be reduced congruently and the fragment is fixed with two additional K-wires. Reduction is confirmed by fluoroscopy, including oblique views into the subtalar joint space corresponding to the Broden views. The amount of correction of the tuberosity joint angle and varus/valgus deformity is confirmed by fluoroscopy. The quality of reduction of the crucial posterior joint facet can be confirmed by open subtalar arthoscopy (2.3 mm/30° arthroscope) after K-wire fixation, to evaluate the areas inaccessible to the eye.

If an intra-articular step is found, the position of the posterior facet should be corrected immediately. After joint reduction, the tourniquet is released. Internal fixation is completed with the use of an anatomically shaped plate affixed to the restored lateral wall of the calcaneus (Fig. 28.16).

Screw osteosynthesis is generally preferred in isolated fractures of the calcaneus instead of K-wire transfixation, because it provides sufficient stability and allows for early mobilization (Fig. 28.16). The exact number and position of screws depend on the individual fracture pattern. When the duration of surgery must be kept to a minimum in polytraumatized patients, K-wires are used instead of screws and are supplemented by tibiometatarsal transfixation or three-point distraction (calcaneal tuberosity, talar head and navicular or medial cuneiform) with an external fixator. If no definitive fixation is done, K-wires and external fixation devices are removed after 10–12 weeks.

This approach is recommended in isolated sustentacular fractures and as a supplement to the extended lateral approach in complex intra-articular fractures with fragmentation of the medial facet. The patient is placed on the operating table in a supine position. A tourniquet is placed on the thigh of the injured leg. Incision is made longitudinally about 3 cm long parallel to the sole of the foot, 1–2 cm distal and anteriorly to the tip of the medial malleolus directly over the palpable sustentaculum. The posterior tibial neurovascular bundle is identified by nearby tendons and left in place. The sustentaculum is also identified. The medial facet is reduced to the corresponding facet of the talus and two long (about 50–60 mm) 3.5-mm compression screws are introduced into the sustentaculum tali along its axis into the main tuberosity fragment.

Deep soft-tissue and bone infection occurs in 1.3–7 % [91, 95]. In such cases, debridement and cultures have to be done until wound swabs are negative. If infection persists, the calcaneal plate has to be removed and replaced by screw osteosynthesis. Antibiotic beads (e.g., gentamycin) are inserted temporarily.

If chronic post-traumatic osteomyelitis develops despite all measures listed above, subtotal or total calcanectomy is inevitable. If soft-tissue coverage cannot be achieved even after management with synthetic skin substitutes or continuous suction, free flaps have to be considered in order to control infection and to avoid a protracted postoperative course [106].

Nonunion is very rare after stable internal fixation and can be treated with bone grafting and fixation using 6.5-mm cancellous screws. A dual approach is associated with an increased incidence of wound edge necrosis.