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Minimally invasive calcaneus fracture treatment

Sinus Tarsi Approach to Financial Disclosure Calcaneus Fracture Evolution or Revolution Marc J. Michaud MD New Hampshire Orthopaedic Center January 24, 2014 Calcaneus Fractures Eric M. Bluman, MD, PhD Most common tarsal bone Assistant Professor Harvard Medical School 1-2% of all bone fractures Lew C. Schon, MD Typically from an axial load: Fall from height Union Memorial Hospital Fracture does not involve the Anterior Process Joint Depression Posterior facet remains Sustentaculum Tali attached to the calcaneus Peroneal Tubercle Sander's Classification Orthopaedic Trauma Protocols: Hansen/Swiontkowski Posterior Calcaneal Sander's Classification Joint Depression S Type I- Non-displaced S Type II/III- have 2 and 3 fragments that are medial or Posterior facet impacted into lateral and subdivided into the body of the calcaneus primary and secondary fracture lines. S Type IV- Severely comminuted Orthopaedic Trauma Protocols: Hansen/Swiontkowski Historical Treatment Historical Treatment 1720 Petit and DeSault in France. First accurate description of treatment of calcaneus fractures. 1948 Palmer Unsatisfied with non-operative and late treatment. Advocated acute treatment through Kocher approach 1908 Cotton and Wilson: Operative treatment contra-indicated S Patients did "wel " and many returned to work S Recommended closed treatment with a medially placed 1952 Essex-Lopresti: sandbag and a hammer to to reduce the lateral wall. S Tongue-type: percutaneous reduction S Reimpact" the fracture S Joint Depression: ORIF 1931Bohler: Advocated operative treatment but technical 1993 Benerschke and Sangeorzan: Surgical treatment with extensile lateral approach, rigid internal fixation, early motion. Infection, malunion, non-union, need for amputation With CT scans, IV antibiotics, fluoroscopy, AO/ASIF techniques, and better anesthesia there has been a trend toward more 1943 Gallie: Subtalar arthrodesis as definitive treatment for aggressive surgical intervention healed, malunited fractures. Indications for Operative Extensile Lateral Approach CONTRAINDICATIONS S Palmer and Letournel S Severely comminuted fracture S Substantial depression S Impaired vascularity S Widening of the heel Full Thickness Flap that protects S Extension into posterior facet S Severe neuropathy or IDDM S Peroneal tendons with displacement of > 2 mm S Unable to be non-weight S ? Vascular supply Associated Complications High Complication Rate Wound complications occur in up to 25% of surgically treated calcaneal fractures Berschke &Kramer Extensile Approach (2003)JOT 17:241 (2011)Foot Ankle Surg 17:233 Tips To Avoid Complications S Allows swelling to go down S Fracture starts to heal S Bony reabsorption Why is this area such a S Extensile approach requires making incisions just Three dimensional blocks of tissue Understanding their boundaries proximal to the arteries supplying the flap fed by source arteries and anastomoses provides the basis for designing incisions and S Little to no underlying muscle to fall back on exposures that preserve blood supply First described by: Tayor and Palmer, Br.J.Plast.Surg (1990) 43:1 Popularized by: Attinger, Plast. Reconstr. Surg.(2006)117.261S Angiosomes of the Foot -main vascular supply to a given angiosome Supply vessels which link adjacent angiosomes to one another Provide safety conduit that allows a given angiosome to provide blood flow to an adjacent angiosome Peroneal Angiosome Peroneal Angiosome Lateral heel is the lateral border of the peroneal angiosome which is fed by the fibular (peroneal) artery, a branch of posterior tibial artery With a calcaneal fracture the choke vessels between the peroneal and anterior tibial angiosomes may not have time to open up An incision above the glaborous juncture leaves intervening tissue between the incision and lateral border of the peroneal angiosome in May take longer in the traumatic setting of soft tissue damage and inflammation Rational for the Sinus Tarsi Initial Management S Always associated with soft S Measure compartment pressure if pain out of proportion S Evaluate type of fracture S Lateral displacement S Varus alignment S Joint Depression S Assess displacement of facet S Check for associated mid foot Confirms posterior facet fracture complexity and calcaneal-cuboid injuries Evaluate the relationship of the sustentaculum tali Calcaneal-cuboid joint displacement Lateral position S Bulky Jones dressing/splint/elevate Thigh Tourniquet S Operate when skin lines present Stable platform with folded blankets S Usually 5-7 days Prep/Drape entire leg S Longer when fracture blisters S Open fractures managed acutely Tools of the Trade Standard approach to sinus tarsi S Extend towards base of 4th S Visualize calcaneal-cuboid joint Elevate extensor digitorum brevis Debride hematoma and small fracture fragments Enter peroneal tendon sheath Reduce Anterior Calcaneus Fix calcaneal-cuboid joint if Elevate and protect tendons Sub periosteal dissection of lateral wall with periosteal elevator Pin anterior calcaneus to sustentaculum tali Open a portion of lateral wall and examine the posterior facet Clinically Oriented Anatomy. Keith L Moore Reduce Posterior Tuberosity Restore calcaneus tuberosity to sustentaculum tali: shortened and in varus With 4 mm Schanz pin: placed lateral or posterior Apply plantar and valgus directed force Translate medially Orthopaedic Trauma Protocols: Hansen/Swiontkowski Manual Traction Over a Bump Translate Medially Intraoperative Axial View Provisional Fixation Progress medial to
Sustentaculum tali is
constant fragment
Restore Gissane's angle
Master Techniques in Orthopaedic Surgery The Foot and Ankle, Kitaoka Reduce Posterior Facet Cannulated Screws to Facet Place into subchondral
Place laminar spreader Freer elevator and dental pick bone of posterior facet
"Trampoline Screw"
Visualize sustentaculum tali Elevate depressed fragments Slide plate onto bone
Contour plate
S I use allograft cancellous bone chips for large voids Make sure it is sitting
Slide plate onto bone
Robert Jones Type Dressing S Irrigation and hemostasis S 2-0 absorbable for deep tissue S Close subQ with 4-0 S Close skin with vertical mattress stitches S Ice and elevate S Remove drain after 1 day Fall from ladder S Remove splint after 10-14 days S Apply cast or boot Joint depression S Remain NWB until healed, typically 6-10 weeks 2.5 months post-op

Source: http://www.nhmi.net/pdf/Michaud_Calcaneus.pdf