Calcaneus Fractures

2014-02-04

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2/4/2014

Fractures of the Calcaneus

R.J. Claridge MD
Mayo Clinic
Scottsdale Arizona

Fractures of the Calcaneus
Evaluation & Indications
R.J. Claridge MD
Mayo Clinic
Scottsdale Arizona

Fractures of the Calcaneus
Disclosures
• No disclosures pertinent to this
presentation

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Fractures of the Calcaneus
Evaluation
• History and Physical:
 Mechanism of injury
 Concomitant injuries
 Diabetes, neuropathy
 Smoking history, vascular disease
 Soft tissue damage
 Bone quality

Fractures of the Calcaneus
Evaluation

Fractures of the Calcaneus
Evaluation

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Fractures of the Calcaneus
Evaluation
• Radiographs:
 Foot, 3 views
 AP ankle
 Harris view
 CT scan
 3D reconstruction
 MRI
 Bone Scan

Fractures of the Calcaneus
Evaluation
• Radiographs:
 Foot, 3 views
 AP ankle
 Harris view
 CT scan
 3D reconstruction
 MRI
 Bone Scan

Fractures of the Calcaneus
Evaluation
• Radiographs:
 Foot, 3 views
 AP ankle
 Harris view
 CT scan
 3D reconstruction
 MRI
 Bone Scan

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2/4/2014

Fractures of the Calcaneus
Evaluation
• Radiographs:
 Foot, 3 views
 AP ankle
 Harris view
 CT scan
 3D reconstruction
 MRI
 Bone Scan

Fractures of the Calcaneus
Evaluation
• Radiographs:
 Foot, 3 views
 AP ankle
 Harris view
 CT scan
 3D reconstruction
 MRI
 Bone Scan

Fractures of the Calcaneus
Evaluation
• Radiographs:
 Foot, 3 views
 AP ankle
 Harris view
 CT scan
 3D reconstruction
 MRI
 Bone Scan

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Fractures of the Calcaneus
Evaluation
• Radiographs:
 Foot, 3 views
 AP ankle
 Harris view
 CT scan
 3D reconstruction
 MRI
 Bone Scan

Fractures of the Calcaneus
Treatment
• Operative: 3 groups
 Always
 Never
 Maybe

Fractures of the Calcaneus
Treatment
• Operative: 3 groups
 Always

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Fractures of the Calcaneus
Treatment
• Operative: 3 groups
 Always

Fractures of the Calcaneus
Treatment
• Operative: 3 groups
 Never

Fractures of the Calcaneus
Treatment
• Operative: 3 groups
 Maybe

6

2/4/2014

Fractures of the Calcaneus
Treatment
• Operative: 3 groups
 Maybe

Fractures of the Calcaneus
Treatment
• Operative: 3 groups
 Maybe

Fractures of the Calcaneus
Treatment
• Operative: 3 groups
 Maybe

7

2/4/2014

Fractures of the Calcaneus
Treatment
• Operative: 3 groups
 Maybe

Fractures of the Calcaneus
Treatment
• Operative: 3 groups
 Maybe

Fractures of the Calcaneus

8

Open Reduction of Calcaneus Fractures

Prof. V. K. Panchbhavi MD, FACS
Chief Division of Foot & Ankle Surgery
Director Foot & Ankle Fellowship Program
University of Texas Medical Branch
Galveston, Texas, USA

Objectives





Patient positioning
Surgical approaches
Reduction maneuvers
Internal fixation methods

Department of Orthopedic Surgery and Rehabilitation

 Positioning – consideration

Department of Orthopedic Surgery and Rehabilitation

 Surgical approach - considerations

Department of Orthopedic Surgery and Rehabilitation

Surgical Approach

Department of Orthopedic Surgery and Rehabilitation

 Reduction maneuvers

Department of Orthopedic Surgery and Rehabilitation

 Reduction of tuberosity to ST
– Restore height
– Restore valgus
– Medial translation

Department of Orthopedic Surgery and Rehabilitation

Donati-Allgower Stitch

Take Home Messages







Understand 3 D anatomy
Study the fracture planes and displacement
Plan the approach
Reduce the articular surface
Restore the height
Restore the tuberosity

Department of Orthopedic Surgery and Rehabilitation

Thank You

2/4/2014

Calcaneal Fractures
• Dr. Alastair Younger
• Associate Professor,
• University of British Columbia

Disclaimers
• Institutional support from Linvatec, Smith
and Nephew, Cartiva, Wright Medical,
Integra foundation, BMTI, Acumed, Bioset,
Synthes.
• Consultant Biomimetics (Wright), Acumed
and Cartiva

Background
• Buckley paper
• Early reports
– No difference with
OR

• Final paper
– Beneficial in select
groups

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2/4/2014

Rates of ORIF British Columbia
Calcaneus ORIF BC
140

120

100

80
Calcaneus ORIF BC
60

40

20

0
2000

2002

2004

2006

2008

2010

2012

2014

Aims of ORIF
• Surgeon must:
–
–
–
–
–
–
–

Restore the tuberosity fragment
Restore the subtalar joint
Reconstruct the medial wall
Reduce the peroneal tendons
Restore height
Avoid wound complications
Release tendons and nerves from the fracture

Why less invasive
•
•
•
•

Wrinkle test
Elevate
Cryocuff
After fracture blisters
resolve

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Technical factors
• Dissection and approach

Technical factors
• Assessment of reduction
• Fixation

Reduction

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Case – tuberosity #
• Running from Hooker
• Skin issues urgent
• Reduction using large
fragment clamp
• Held with ex fix
• Medial and lateral bar

Less invasive – still need to
reduce the peroneal tendons
• Reduction of peroneal tendons

Calc fracture – arthroscopic
reduction

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Missed calcaneal fracture
• 4 months out

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Calcaneal fracture – 3 weeks out
• 60 year old
• Fell from boxes in a storage locker
• Healthly – enjoys golf

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Minimally invasive calcaneus

45 year old
• Movie set constructor
• Fell off the top of a 14 foot cowboy set
building

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Bilateral calcaneal fractures

Left side

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Bilateral calc orif

Calc fracture – arthroscopic
reduction
Bilateral calcaneal fracture case

13

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28 year old male
• Fell off bus stop
• Plays hockey
• Works as a doorman downtown hotel

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Compound calcaneus
• Fell from height
• Large medial compound wound
• Drug abuse, smoker, not employed

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Bilateral calcaneal fractures
• Fell from tree
• 45 year old male

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Summary
• ORIF beneficial in most cases
• Techniques are changing to reduce
morbidity and expanding indications
• Late reconstruction is difficult and may not
restore function
• Make sure you restore normal anatomy
– Early and late
– Open or percutaneous

Thank You

23

2/4/2014

Steven Steinlauf, MD
The Orthopaedic Foot and Ankle Institute of South Florida
Clinical Assistant Professor University of Miami
Memphis, TN October 2013

Disclosure
 I am a consultant and designer for Smith and Nephew

(VLP Foot System)
 I Instruct for the AO

Complications of Extensile
Lateral Approach
 Poor wound

healing
 Risk of infection
 Significant scar

tissue
 Decreased ROM

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2/4/2014

A Better Solution?
Minimal Incision Techniques
 The concept = Less damage
to the soft tissues
 Biologic fixation principles

 Medial – Bordeaux, no
direct reduction of post
facet or ant calcaneus
 Medial and limited lateral
 Percutaneus Fixation
 Tongue and Tuberosity
fractures
 Sinus tarsi approach
 Screws only
 Screws and mini-plates
 Custom plates

Which is better?
 Kline AJ, et. Al. FAI 2013, June, Sinus Tarsi Vs. extensile
lateral
 Retrospective
 79 - extensile lateral approach
 33 - minimally invasive
 Wound complication –
 29% extensile vs. 6% minimally invasive
 20% extensile - secondary surgery, 2% minimally invasive
 FFI - 31 extensile group vs. 22 minimally invasive
 VAS pain - 36 extensile, 31 minimally invasive
 84% extensile satisfied, 94% minimally invasive
 no differences - Bohler's angle and angle of Gissane.

The sinus tarsi approach in
displaced intra-articular calcaneal
fractures: a systematic review.
•
•
•
•

Schepers T Int Orthop, 2011
8 case series reporting on 256 patients with 271 calcaneal fractures
good to excellent – ¾
minor wound complications of 4.1% was reported and major wound
complications in 0.7%.
• The results, i.e. functional outcome and complication rates, of the sinus
tarsi approach compare similarly or favourably to the extended lateral
approach.

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2/4/2014

Mini-incision Treatment for
calcaneal fractures
 Workup - same
 Radiographs and CT – same
 Timing – different
 Extensile lateral incision – Once swelling goes down
(usually within 3 weeks)
 Mini-incision techniques - 1 – 14 days (The earlier
the better, soft tissues permitting)
 Preop –
 RICE
 Jones dressing

Indications
 Very Narrow at first





A learning curve exists
Easier if you have performed many through an extensile
lateral exposure
Understand the anatomy and the fracture

Indications
 You must have good
bone in 3 locations:
 Anterior, Posterior
tuberosity, Constant
fragment
 These are the areas for
needed screw fixation
 Specific percutaneus
plate - fracture lines
extending to these
regions – locking
screws help

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2/4/2014

Indications
 Specific Fracture Patterns:
 Sander’s 2 part (Easiest)
 Sander’s 3 Part with an anterior central part (Difficult)
 Sander’s 4 part (Fairly Straight forward)
 Need to reestablish articular anatomy grossly and then fuse
 Excellent for open injuries in the correct setting

Contraindications
 Sander’s 3 part fractures with posterior fragments
 You cannot get to them from the sinus tarsi incision

 Fractures where you do not think that you can
achieve an anatomic reduction of the joint
 Remember – Small Incisions with a poor
reduction achieve nothing!!!

Positioning
Supine for unilateral or
bilateral

Lateral decubitus

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2/4/2014

Percutaneus Plate
Sanders 2 Part

Step 1 -Medial Ex-Fix Placement
Placement of medial ex- fix:
 Enables you to “pull” the
posterior tuberosity out of
the way.
 This allows for:
 Easier reconstruction of
the posterior facet
 Easier correction of
height and varus
 No need for a medial
screw
 Greatest advance in
technique

Steps 2 Incision /
Disimpaction
 Sinus tarsi incision –
Dorsal to the peroneals
Keep the peroneals in
their sheath
Compress Lateral wall
“blow-out”
Make path for the plate –
stay on the outside of the
posterior tuberosity
Disimpact medial wall –
Curved elevator
Correct varus and height

5

2/4/2014

Steps 2 - Incision / Disimpaction

Steps 2 - Incision / Disimpaction

Step 3 -Reduction and
stabilization of posterior facet

Pulling the posterior tuberosity out of the way makes the posterior facet
reduction possible
Lag the posterior facet with 2.0 to 3.0mm screws as needed (canulated vs. solid)
Aim towards sustentaculum as much as possible
Confirm reduction with scope and fluro

6

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Step 4 - Plate Placement

Step 4 - Plate Placement

Step 4 - Plate Placement

7

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Finals

 Start Early

Post-op Protocol

Motion – 7 days
+/- (when the
wound is ready)
 Better final
ROM?

8

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Delayed Wound Healing
 Rough with tissues
 Incision too small
 Fix after 2 weeks
 Move too soon (less

than 1 week)
 Stop movement until

wound is healed

Infection
 Mini incision
 ORIF and primary fusion

for an open Sander’s 4
fracture
 Vac
 Abx
 No need for a flap
 Hopefully risk will be
less

Sural Nerve Injury
 Take care to

place screws
dorsal or plantar
to the nerve

9

2/4/2014

Peroneal Tendonitis
 Protect the tendons

throughout the case
 Keep them in their

sheath
 Possibly more pain

and need for ROH?

Our Study:
 Total patients undergoing percutaneus plating

(minimum f/u 3 mos.): 49 pts.
 Total Fxs.: 51
 2 patients with Bilateral fxs had both sides tx with ORIF
 Males – 33 (34fxs), Females – 16 (17 fxs)

Patients
 Not at high risk for infection 26 pts. (26 fxs.)



1 infection at operative site
1 infection at site of posterior
skin necrosis near tongue fx.

 High Risk Patients” –
 Smokers: 14 pts. (16fxs.)(No

infecs)
 Diabetic: 3 pts. (No infecs)
 Smokers (plus diabetes /

HIV): 2 pts. (No infecs)
 Open Fractures: 4 pts. (1

infection)

 High Risk Group 1
infection in 25 cases.
 No infections since 2008.
 9 pts - extension for
stabilization of pers – 0
infecs.

10

2/4/2014

Our Study:
 Delayed wound Healing – 5 pts.
 None required additional surgery or special treatment
 Painful hardware requiring removal – 4 pts.

Conclusions
 The sinus tarsi approach offers the following benefits:
 Fewer serious wound complications
 Lower risk of infection


Especially in high risk groups

 Anatomic reduction of Sanders type II and some type III

fractures (confirmed with an arthroscope)
 Able to use for Type IV fractures (primary subtalar fusion)
 Functional outcome is likely similar to extensile lateral

approach (We need to complete phase 2)

11

2/3/2014

SURGICAL MANAGEMENT OF
THE CALCANEAL MALUNION

MICHAEL P. CLARE, M.D.
FLORIDA ORTHOPAEDIC INSTITUTE
TAMPA, FLORIDA, USA
VUMEDI CALCANEUS WEBINAR 2014

CALCANEAL LENGTH
Ø

MAINTAINS LATERAL COLUMN LENGTH
Ø PROTECTS POSTEROMEDIAL ARCH

Ø

REFLECTED BY CALCANEAL PITCH ANGLE

CALCANEAL HEIGHT
Ø

DETERMINES ORIENTATION OF TALUS:
INDIRECTLY AFFECTS ANKLE DF

1

2/3/2014

RESIDUAL ARTICULAR INCONGRUITY
Ø

POST-TRAUMATIC ARTHRITIS

Ø

SUBTALAR JNT

Ø

CALCANEOCUBOID JNT

LOSS OF CALCANEAL HEIGHT
Ø
Ø
Ø

RELATIVE HORIZONTALIZATION OF TALUS
ANTERIOR ANKLE IMPINGEMENT
INDIRECT LOSS OF ANKLE DORSIFLEXION

LOSS OF CALCANEAL HEIGHT
Ø

DECREASED GASTROC-SOLEUS LEVER ARM

Ø

LIMB-LENGTH INEQUALITY

2

2/3/2014

TUBEROSITY MALALIGNMENT
Ø

ALTERED SHOE WEAR / GAIT PATTERN

LATERAL WALL EXPANSION
Ø

LATERAL SUBFIBULAR IMPINGEMENT

Ø

PERONEAL TENDON
Ø STENOSIS
Ø TENDINITIS
Ø DISLOCATION

ANTERIOR PROCESS DISPLX
Ø
Ø

BONY BLOCK TO SUBTALAR MOTION
IMPINGEMENT PAIN IN SINUS TARSI

3

2/3/2014

CHRONIC 3-JOINT INJURY

CLINICAL EVALUATION
Ø

STANDING EXAMINATION
Ø VARUS

Ø

/ VALGUS MALALIGNMENT

ASSESS LATERAL HINDFOOT SKIN
Ø PREVIOUS

INCISION(S)
MOBILITY
Ø NICOTINE USE
Ø OVERALL

RADIOLOGIC EVALUATION
Ø

WEIGHTBEARING FILMS ESSENTIAL !
Ø STANDARD

Ø HARRIS

Ø

WB 3-VIEWS ANKLE & FOOT
AXIAL VIEW

CT SCAN
Ø AXIAL

/ SAGITTAL / CORONAL VIEWS

4

2/3/2014

DETERMINE ORIGINAL FX PATTERN
Ø

SANDERS CLASSIFICATION
Ø SANDERS,

Ø

ET AL. CORR 290, 1993

RELEVANT ACUTE
PATHOANATOMY

DETERMINE MALUNION PATTERN
Ø

STEPHENS-SANDERS CLASSIFICATION
Ø

STEPHENS & SANDERS, FAI 17, 1996

Ø

RELEVANT CHRONIC PATHOANATOMY

Ø

UNDERSTANDING MALUNION “PERSONALITY”
Ø

TECHNICAL STEPS OF DEFORMITY CORRECTION

MALUNION “PERSONALITY”

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EXTENSILE LATERAL APPROACH
Ø

LATERAL DECUBITUS POSITION

Ø

FULL-THICKNESS FLAP

LATERAL WALL EXOSTECTOMY
Ø

COTTON, ANN SURG 74, 1921

Ø

A/O OSTEOTOMY SAW

Ø

SLIGHTLY ANGLED
IN SAGITTAL PLANE

Ø

PRESERVE MORE
BONE PLANTARLY

Ø

PROTECT TALOFIBULAR JNT

LATERAL WALL EXOSTECTOMY
Ø

COMPLETE WITH OSTEOTOME
Ø

Ø

EXIT WITHIN LATERAL CALCANEOCUBOID JOINT

PRESERVE AS SINGLE FRAGMENT

6

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SUBTALAR JOINT MOBILIZATION
Ø
Ø

OSTEOTOME IN PLANE OF POSTERIOR FACET
COMPLETE WITH LAMINAR SPREADER

SUBTALAR JOINT PREPARATION
Ø

PRESERVE SUBCHONDRAL PLATE

Ø

SHARP PERIOSTEAL ELEVATOR

Ø

SUBCHONDRAL PERFORATIONS

Ø

2.5MM DRILL BIT

CALCANEAL OSTEOTOMY (TYPE III)
Ø

VARUS: DWYER OSTEOTOMY

Ø

VALGUS: MEDIAL SLIDE

Ø

~ PARALLEL TO
POSTERIOR FACET

7

2/3/2014

BONE BLOCK INSERTION
Ø

KALAMCHI & EVANS, JBJS-BR 59, 1977

Ø

LAMINAR SPREADER POSTEROMEDIALLY

Ø

SHAPE GRAFT WIDTH-WISE

Ø

BROADEST PORTION POST-MED

Ø

SUPPLEMENTAL VOID FILLER / GF

DEFINITIVE STABILIZATION
Ø
Ø

6.5 - 8.0 MM CANNULATED SCREWS
DIVERGENT PATTERN

DEFINITIVE STABILIZATION
Ø

ANTERIOR PROCESS:TALAR HEAD

8

2/3/2014

DEFINITIVE STABILIZATION

DEFINITIVE STABILIZATION

PERONEAL TENOLYSIS
Ø

FREER ELEVATOR ALONG
UNDERSURFACE OF FLAP

Ø

MOBILIZE PERONEAL TENDONS

Ø

PERONEAL GROOVE TO CUBOID TUNNEL

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WOUND CLOSURE
Ø

DEEP DRAIN / ABSORBABLE SUTURE

Ø

ENDS TOWARD APEX (ADVANCING FLAP)

WOUND CLOSURE
Ø

MODIFIED ALLGÖWER-DONATI
Ø 3-0

MONOFILAMENT

POST-OPERATIVE PROTOCOL

SPLINT / CAST IMMOBILIZATION
NON-WEIGHTBEARING X 10-12 WEEKS
Ø BOOT / ADVANCE WEIGHTBEARING
Ø BOOT TO SHOE / PROGRESS ACTIVITY
Ø
Ø

10

2/3/2014

FX-DISLX VARIANT MALUNION
Ø

ROMASH OSTEOTOMY
Ø ROMASH,

CORR 290, 1993

Ø

OSTEOTOMY THRU
PRIMARY FX LINE

Ø

RESTORE HEIGHT

Ø

SUBTALAR ARTHRODESIS

POOR LATERAL SKIN / OLD INCISION
Ø

LATERAL WALL EXOSTECTOMY /
BONE BLOCK ARTHRODESIS

Ø

~ GALLIE INCISION /
VERTICAL LIMB OF E-L

Ø

CARR, ET AL. FOOT & ANKLE 9, 1988

STILL A SALVAGE PROCEDURE
Ø
Ø

CLARE, ET AL. JBJS-AM 87, 2005
RADNAY, ET AL. JBJS-AM 91, 2009

Ø

VERY DIFFICULT TO COMPLETELY
RESTORE HINDFOOT ANATOMY
IN CALCANEAL MALUNION

Ø

MALUNION SURGERY CANNOT RESTORE
HINDFOOT MORPHOLOGY LIKE ACUTE
FRACTURE REDUCTION (ORIF) CAN

11

2/3/2014

ACUTE ORIF BENEFICIAL
Ø
Ø

CLARE, ET AL. JBJS-AM 87, 2005
RADNAY, ET AL. JBJS-AM 91, 2009

Ø

RESTORATION OF CALCANEAL HEIGHT /
LENGTH / OVERALL MORPHOLOGY

Ø

EVEN IN THE EVENT OF LATE PTOA:
IN-SITU SUBTALAR ARTHRODESIS

SUMMARY
Ø

3-JOINT INJURY: 3-JOINT MALUNION

Ø

DETERMINE ACUTE PATHOANATOMY:
CHRONIC PATHOANATOMY

Ø

INDIVIDUALIZE TREATMENT

Ø

RESTORING CALCANEAL HEIGHT / WIDTH
ELIMINATING LATERAL WALL EXPANSION
MOBILIZING PERONEAL TENDONS

Ø
Ø

12
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