comtemporarycalcaneal#s

Contemporary

management of

calcaneal fractures

Dr Yeap Ewe JuanMBBS (Mal), MS Ortho (Mal)

Fellowship in Foot & Ankle Surgery (USA & Spore)

Tuanku Fauziah Hospital

Head, Clinical Research Centre, Perlis

Honorary Lecturer ACMS, Unimap

Introduction

Major wound complications

is THE serious concern in

treating calcaneal fractures

Soft tissue around the

calcaneum is thin and calcaneum is thin and

especially over the lateral

wall

Injury (2004) 35 ; S-B55-63

Introduction

Wound edge necrosis is

seen in up to 14% with

the extended lateral

approach

Abidi et al Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Foot Ankle Int; 19(1998) : 856861.

Introduction

Infection rates up to

8.5% for closed

fractures

As high as 60% for open

Foot Ankle Int (2000) 21;105-113J Bone Joint Surg Am (2003) 85;2276-82Arch Orthop Trauma Surg (1998) 117(8);442-7

Introduction

Folk et al reported

25% of wound complications in 190 patients

21% requiring further surgery

J Orthop Trauma 1999; 13(5): 369-72

Introduction

Hazards with medial approaches lie in the

neurovascular bundle

Introduction

Combined medial and lateral approaches

Rate of wound edge necroses reaches 27%

Stephenson JR (1987) Treatment of displaced intra-articular fractures of the

calcaneus using medial and lateral ap-proaches, internal fixation, and early

motion. J Bone Joint Surg Am; 69(1):115130

Introduction

Other complications

Poor exposure

Poor reduction

Introduction

Lack of training & expertise

Introduction

Introduction

Closed treatment options popular

Risk of incomplete reduction

Secondary OA of subtalar joint

Shortening Shortening

Calcaneovalgus deformity

Subfibular impingement

Broad heel (shoewear problems)

Indications for MIS

Emergency treatment of

complex foot trauma

Open calcaneal

fractures

Closed fractures with

soft tissue compromise,

e.g. skin necrosis from

grossly displaced bone

fragments

Zwipp H. (1994) Chirurgie des Fues. Wien, New York: Springer

Indications for MIS

Polytrauma

Contraindications to open surgery

Poorly controlled diabetes

Smokers Smokers

Immunodeficiency

Blistering

Superficial contamination

Vascular compromise

Simpler injury patterns, e.g. Sanders IIZwipp H. (1994) Chirurgie des Fues. Wien, New York: SpringerLevine DS, Helfet DL (2001) An introduction to the minimally invasive osteosynthesis of intra-articular calcaneal fractures. Injury; 32(1):SA5154.

Emergency fixation

Treat soft tissue

Limited lag screws or percutaneous K wires

Temporary external fixation

Standard fixation within 2-3 weeks Standard fixation within 2-3 weeks

However

Due to great variety of fracture patterns

No uniform technique exists

Percutaneous techniques

Closed reduction by traction, pin leverage and

compression

K wire and external fixation

Forgon M (1992) Closed reduction and percutaneus osteosynthesis: technique and results in 265 calcaneal fractures.In: Tscherne H, Schatzker J. Major fractures of the pilon, the talus and the calcaneus. Berlin, Heidelberg, New York: Springer Verlag.


Kortmann et al reported better results after

closed reduction and fixation in an Ilizarov

frame than after conservative treatment.

Kortmann HR, Wolter D, Bisgwa F et al. (1992)

[Treatment of calcaneus and mid-foot fractures using

closed reposition and fixation with the Ilizarov fixator.]

Unfallchirurg; 95:541546.


Essex-Loprestireduction (Westhues)

Indirect reduction by percutaneous leverage with pin in main with pin in main tuberosity fragment

Reduction maintained with POP

Useful in tongue type fractures (Sanders IIC)

Essex-Lopresti P (1952) The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg; 39(157): 395419.


Zwipp combined percutaneous reduction and screw fixation with subtalar arthroscopy

Indicated for Sanders IIA and B

Reduction performed via Essex-Lopresti method

Separate fragments manipulated with K wires or Separate fragments manipulated with K wires or elevators

2.7mm 30 arthroscope

Gavlik JM, Rammelt S, Zwipp H (2002) Percutaneous, arthroscopically-assisted osteosynthesis of calcaneus fractures. Arch Orthop Trauma Surg; 122(8):424428.

Arthroscopically assisted

percutaneous screw fixation

Calcaneal fracture Sanders IIB

Pre-op 2

Calcaneal fracture Sanders IIB

Post-op 22

Open calcaneal fracture Sanders III

Calcaneal fracture Sanders III

Arthroscopically assisted

percutaneous screw fixation If inadequate reduction by closed means,

then open reduction and plating

Reported 3 out of 21 cases

No compartment syndrome

Average AOFAS hindfoot score of 94.1 out of 100 @1 yr Average AOFAS hindfoot score of 94.1 out of 100 @1 yr

My own patients ~ 85 to 90 @ 3 to 6 mths

Rammelt S, Gavlik JM, Barthel S et al. (2002) The value of subtalar arthroscopy in the management of intra-articular calcaneus fractures. Foot Ankle Int; 23:906916.

Gua Kelam

Thank you

comtemporarycalcaneal#s

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