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Percutaneous reduction and low-profile plating are keys for limited incision calcaneus fracture fixation
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Intra-articular calcaneus fractures are high-energy injuries that can result in significant functional loss and morbidity. The management of displaced intra-articular calcaneus fractures is controversial as studies have shown advantages and disadvantages of both nonoperative care and surgical intervention. When surgery is performed, a traditional approach using an extensile L-shaped lateral incision with lateral plating has been associated with high rates (up to 40%) of wound-healing problems and superficial and deep infection. Wound complications can result in reoperation, plastic surgical intervention and amputation in severe cases. The vascular supply of the lateral hindfoot relies upon the lateral calcaneal branch of the peroneal artery, which is susceptible to injury during an extensile L-shaped approach.
Less-invasive surgical techniques for calcaneus fracture fixation have been developed in recent years to optimize the benefits of surgery while lowering the complication risks. The goal is to obtain anatomic fracture reduction and stabilization with minimal soft-tissue dissection. Early results have shown lower complication rates with these techniques with good clinical and radiographic outcomes in certain fracture patterns and patient cohorts. Comparing our extensile L-shaped approaches to a limited incision sinus tarsi approach, we found a 23% reduction in wound complications and 18% reduction in the reoperation rate using less-invasive techniques. Both groups had similar clinical outcome scores with no noted differences in final postoperative Bohler’s angle or angle of Gissane on weight-bearing radiographs.
We believe that limited incision approaches may be particularly useful in the treatment of displaced intra-articular calcaneus fractures (DIACFs) in higher-risk patients with soft-tissue compromise, multiple comorbidities, diabetes, obesity and/or a positive smoking history. A comprehensive understanding of the clinical and radiographic anatomy of the hindfoot is necessary when performing limited incision approaches for intra-articular calcaneus fractures.
Limited incision sinus tarsi technique
Primary indications to use less-invasive calcaneal approaches include displaced Essex-Lopresti fractures, Sanders type II fractures, Sanders type III fractures in patients with multiple co-morbidities, and DIACF variants with minimal comminution of the posterior facet. Surgical intervention should be performed within 2 weeks to 3 weeks from the time of injury as restoration of calcaneal length and height can be difficult to obtain through smaller incisions when treatment is delayed. We have found that fracture fragments are relatively easy to manipulate and reduce with ligamentotaxis if surgery is done within the first 2 weeks from injury.
Preoperative lateral radiograph (a) and sagittal (b), coronal (c) and axial CT cuts (d) of a 42-year-old male laborer with a smoking history who fell off of a 10-foot roof and sustained a right-sided closed, intra-articular calcaneus fracture. Imaging shows a tongue-type fracture with significant posterior facet depression and reduction in Bohler’s angle.
Images: Hsu AR and Cohen BE
Our current preference is to use a small 2-cm to 4-cm sinus tarsi incision in combination with cannulated 7.3-mm screws (Synthes; West Chester, Phila.) and a low-profile, anatomically contoured calcaneal plate with 3.5-mm screws (MINI-Calc, Acumed; Hillsboro, Ore.) for fixation. Minimal dissection and manipulation of the peroneal tendons is performed, thus reducing the risk of tendon disruption and subsequent irritation. In addition, the sural nerve is largely avoided, thus lowering the risk of neuritis and neuroma formation after surgery. The sinus tarsi approach is extensile, allows for direct visualization of the posterior facet and can be used later on if future surgery is required for subtalar arthrodesis.
There is a learning curve associated with less-invasive techniques and a potential complication is inadequate fracture visualization and reduction. Therefore, the length of the incision should be increased accordingly based on fracture pattern and if multiple reduction attempts are unsuccessful.
Preparation, setup and approach
Before surgery, it is important to perform a thorough history and physical exam of the patient to determine if any risk factors are present, in particular diabetes, vascular disease and smoking history. Close attention should be paid to the amount of lateral hindfoot swelling and the presence of any open wounds or fracture blisters. Preoperative radiographs and CT cuts need to be carefully analyzed for bone quality, fracture line location, orientation, number of fragments and degree of comminution (Figure 1). Minimally displaced Sanders type I fractures can be treated nonoperatively with immobilization while Sanders type IV fractures with significant posterior facet comminution may require primary fixation with concurrent subtalar arthrodesis.
Planned 2-cm to 4-cm incision over the sinus tarsi with the patient positioned prone with the foot at the end of the bed (a). After careful dissection, the depressed posterior facet is directly visualized along with the peroneal tendons located posteriorly (b). A small periosteal elevator is placed under the posterior facet fragment to elevate it up into an anatomic position (c). C-arm is positioned for an axial heel view and a 2.8-mm Steinman pin is inserted into the center of the posterior fragment to serve as a joystick (d). Lateral radiographs are taken as the Steinman pin is used to lever the posterior fragment into place along with the periosteal elevator (e). Once the posterior fragment is reduced, a 0.045 K-wire is inserted into the fragment and across the subtalar joint into the subchondral bone of the talus for provisional fixation (f). The Steinman pin is then removed and the guide pin for a 7.3-mm cannulated screw (Synthes; West Chester, Phila.) is inserted into the anterior aspect of the calcaneus for axial support and later screw placement (g).
In the OR, patients are positioned prone or in a lateral position using a beanbag with the foot at the end of the bed and a tourniquet on the proximal thigh (Figure 2). A 2-cm to 4-cm incision is made over the sinus tarsi following a line from the tip of the fibula to the base of the fourth metatarsal. Dissection is carefully carried down to the posterior facet as the extensor digitorum brevis is retracted cephalad and the peroneals retracted posteriorly to avoid damage. There is often fibrous debris and fat within the sinus tarsi that needs to be removed with a small rongeur in order to properly visualize the articular cartilage. A C-arm is brought in from the ipsilateral side to facilitate acquisition of multiple lateral and axial heel radiographs.
Elevator and Steinman pin joystick
The depressed posterior facet is directly visualized and a knife is used to sharply demarcate the exposed borders of the fracture fragment. A small Joker periosteal elevator is then placed under the posterior facet fragment to elevate it up into an anatomic position. C-arm is positioned for an axial heel radiograph and in the case of an Essex Lopresti-type fracture a 2.8-mm Steinman pin is inserted into the center of the posterior fragment percutaneously. The Steinman pin and elevator are used together to lever the posterior fragment into place. Once the posterior fragment is anatomically reduced, a 0.045 K-wire can be inserted into the fragment and across the subtalar joint into the subchondral bone of the talus to hold the fragment in a reduced position. In the case of a more typical Sanders type II or III fracture a provisional pin is placed across the posterior facet into the sustentaculum tali. In these fractures, a percutaneous Schanz pin is also placed in the calcaneal tuberosity to restore axial height and length and correct any varus of the heel.
A low-profile, anatomically contoured calcaneal plate (MINI-Calc, Acumed; Hillsboro, Ore.) is inserted through the sinus tarsi incision using lateral radiographs. The plate is provisionally held in place using an olive wire and a hemostat is used through the screw holes to make small adjustments in plate position (a). Several 3.5-mm locking screws are inserted lateral to medial in the anterior and posterior aspects of the plate for initial fixation (b). An axial heel radiograph is taken to ensure proper screw length and avoid disruption of the flexor hallucis longus tendon beneath the sustentaculum tali (c). Intraoperative view of the calcaneal plate in correct position with initial fixation in place is seen (d).
The Steinman pin is then removed and a guide pin for a 7.3-mm cannulated screw is inserted posteriorly directed into the anterior aspect of the calcaneus. This guide pin serves as an axial support to maintain calcaneal height and alignment, supports the posterior facet and is used later on for screw insertion. The central bony void that remains in the calcaneus can be filled with bone graft substitutes or synthetics, but it is not our standard protocol to do use any adjuvants in acute calcaneus fractures.
Plate insertion and fixation
A small, full-thickness soft-tissue envelope is created using an elevator to allow for plate insertion. A low-profile (1.25-mm thick), anatomically contoured calcaneal plate is then inserted through the sinus tarsi incision using lateral radiographs (Figure 3). The size, position and configuration of the plate can be tailored to the individual fracture pattern. The plate is provisionally held in place using olive wires placed through the incision or through stab incisions. A hemostat can be used through the screw holes to make small adjustments in plate position. Non-locking and locking 3.5-mm screws are inserted lateral to medial to engage the sustentaculum, restore calcaneal height and stabilize the posterior facet. An axial heel radiograph is taken to ensure proper screw length and avoid damage to the flexor hallucis longus tendon beneath the sustentaculum tali.
A 7.3-mm cannulated fully-threaded screw is inserted over the guide pin followed by two additional 3.5-mm locking screws in the calcaneal plate for final fixation. The posterior facet fragment is confirmed to be reduced with restoration of Bohler’s angle on lateral radiographs (a). AP (b) and axial heel views (c) of the final construct show anatomic calcaneal height, width and alignment. Final wound length measures approximately 4 cm prior to subcutaneous and skin closure (d).
Final construct and rehabilitation
A 7.3-mm cannulated fully threaded screw is inserted over the posterior to anterior guide pin to restore and stabilize axial length and alignment and serve as a kickstand (Figure 4). No pre-drilling is required, and the stab incision for the guide pin must be slightly enlarged to accommodate the size of the screw head. Fully threaded 7.3-mm screws are preferred over partially threaded screws in order to maintain axial length. An additional large cannulated screw can be added as needed depending on bone quality and fracture characteristics. Two to three additional 3.5-mm locking screws are then inserted in the calcaneal plate for final fixation through the incision or stab incisions as needed. Lateral radiographs are carefully inspected for anatomic reduction of the posterior facet fragment and restoration of Bohler’s angle. A small freer can used to directly palpate the subtalar joint to ensure articular congruity. Final lateral, AP and axial heel radiographs are taken, and the subcutaneous tissues and skin are closed in a layered fashion. Patients are placed in well-padded posterior splint and made non-weight bearing with strict elevation.
Postoperative weight-bearing lateral (a) and heel radiographs (b) 3 months after surgery demonstrate maintenance of hardware position and anatomic reduction of intra-articular calcaneus fracture. The patient had no wound complications or sural neuritis, and was able to return to ambulation in regular shoes with minimal pain.
Sutures are removed 2 weeks after surgery with transition into a non-weight bearing tall CAM boot. Range of motion exercises are started at 2 weeks to help reduce stiffness and peroneal tenosynovitis. Progressive weight-bearing and physical therapy is started 6 weeks to 8 weeks after surgery in the tall CAM boot. Full weight-bearing in a regular shoe is allowed 12 weeks to 16 weeks after surgery with repeat lateral and axial heel radiographs to evaluate maintenance of fragment reduction and hardware position along with fracture consolidation (Figure 5). Patients are release to full activity including running and jumping 16 weeks after surgery pending clinical exam and fracture healing on radiographs.
References:
Agren PH, et al. J Bone Joint Surg Am. 2013; doi:10.2106/JBJS.
Bruce J, et al. Cochrane Database Syst Rev. 2013; doi: 10.1002/14651858.CD008628.pub2.
Buckley R, et al. J Bone Joint Surg Am. 2002;84(10):1733-1744.
Hsu AR, et al. J Am Acad Orthop Surg. 2015 (In press).
Kline AJ, et al. Foot Ankle Int. 2013;doi: 10.1177/1071100713477607.
Randle JA, et al. Clin Orthop Relat Res. 2000;377:217-227.
Sanders R, et al. Clin Orthop Relat Res. 1993;290:87-95.
For more information:
Andrew R. Hsu, MD, and Bruce E. Cohen, MD, are from the OrthoCarolina Foot & Ankle Institute, Charlotte, NC. They can be reached at 2001 Vail Ave., Suite 200B, Charlotte, NC 28207. Hsu’s email: andyhsu1@gmail.com. Cohen’s email: bruce.cohen@orthocarolina.com.
Disclosures: Hsu reports no relevant financial disclosures. Cohen reports he receives royalties from Arthrex Inc., DJ Orthopaedics and Wright Medical Technology Inc.; is a paid consultant for Amniox, Arthrex Inc., and Wright Medical Technology Inc.; and receives research support from Wright Medical Technology Inc.