The calcaneus is the heel bone. A fracture or break of the calcaneus can occur after a fall from a height or car accident. Treatment of these fractures may require surgery if the broken bone is not in good alignment.
The goal of heel fracture surgery is to restore the shape of the heel bone as close to normal as possible. Restoration of normal alignment and contour is considered the best way to restore function and minimize pain.
Surgery is recommended when a broken heel bone has lost its alignment. Your foot and ankle orthopaedic surgeon typically identifies this type of fracture after performing a physical examination and obtaining standard foot and ankle X-rays. The specific type, pattern, and classification of the fracture is best made through a CT scan. Your surgeon may require both X-rays and a CT scan to determine if surgery is your best option.
Not all heel fractures require surgery. Surgery may not be needed if the shape of the heel is generally in tact and the alignment is adequate. Patients with diabetes and smokers are at increased risk for infection, wound healing, and bone healing problems. Patients with poor blood flow may also have difficulty healing properly. Elderly individuals may have difficulty with surgical rehabilitation.
Heel surgery often is delayed due to the swelling that can accompany these injuries. It may be severe enough to delay surgery for weeks or preclude it altogether. Surgery can safely proceed when the skin at the surgical site at the lateral heel wrinkles, indicating the dangerous swelling has gone away. Medications such as immunosuppressants or steroids may slow healing and delay or preclude surgery.
The most common surgical techniques foot and ankle orthopaedic surgeons perform to treat broken heel bones involve cutting through the skin to place the bone back together and using plates and screws to hold the alignment until the bones heal. In a classic "open" procedure, your surgeon will make an incision over your heel. The incision is likened to a hockey stick or large "L" where the overlying nerve and tendons are moved out of the way. The fracture pieces are restored to the best possible position and a plate and screws hold the fragments in place.
The technique of "closed" reduction and percutaneous fixation can sometimes be utilized. In this procedure, your surgeon makes multiple small incisions in critical areas around the heel, realigns the broken fragments with the help of X-rays, and places screws through the skin to hold the position.
The size and location of the incision and the type of screws and plates used are based on skin quality and the surgeon's judgment on how to best access and fix the pieces of the broken bone.
Specific Technique
General anesthesia is typically used to put a patient to sleep during surgery. A regional nerve block is commonly used to help with pain control after surgery. The addition of a regional block can provide 12-24 hours of pain control after surgery. Surgery can be a same-day procedure or planned with a hospital stay.
A tourniquet is used to minimize bleeding and to ensure proper visualization of critical structures that are protected during the surgery. For the standard open approach, a hockey stick or "L" incision is made on the outside of the heel. The sural nerve and the peroneal tendons are moved out of the way and the skin is held back by placing wires in key positions. Your surgeon will put the bony fragments into position to restore the general alignment of the heel.
All pieces of the bone are temporarily held in position with small removable wires. The wires are then removed, and a plate and screws are placed. Your surgeon will close the skin and apply post-surgical dressings and typically a splint to control swelling and to protect the heel bone after surgery.
Expect a lengthy recovery after calcaneus fracture surgery. After the skin sutures are removed, you will be given a short leg cast or boot to protect the repaired bone. You should not put weight on your foot for at least 6-8 weeks until there is sufficient healing of the fracture. The foot remains very stiff and some permanent loss of motion should be expected. Most patients have at least some residual pain despite complete healing.
Arthritis is a very common problem after a calcaneus fracture even if the broken bone is restored to good alignment. If you had misalignment of the broken calcaneus, particularly involving the joint, you can expect to develop some arthritis despite having surgery. If arthritis pain and dysfunction of the foot become severe, then further surgery may be required.
Heel bone fractures often are severe and can be life-changing.
X-ray of the heel after calcaneus fracture surgery with hardware in place
All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.
Complications from treatments for displaced calcaneus fractures can be severe. The most common early complications are with skin healing and nerve stretch. Most wound healing complications can be treated with wound care. Occasionally your surgeon may recommend further surgical treatment to treat would and/or bone healing problems. The development of a deep wound infection often requires surgery and antibiotics. Nearly all nerve stretch complications will resolve over time.
Arthritis after a broken heel is very common with or without surgery. The arthritis often develops due to the injury to the bone and the cartilage that lines the bone, not as a result of the treatment.
No. The main reason to remove hardware is pain due to irritation of the soft tissue. Your surgeon will make sure the fracture has healed enough before removing the hardware.
Original article by Christopher Gentchos, MD
Contributors/Reviewers: Glenn Shi, MD; Andrew Pao, MD; Wen Chao, MD
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