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Calcaneal fracture- fixation with extended lateral approach and ZimmerBiomet ALPS plate

    Overview

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    Learn the Calcaneal fracture: fixation with extended lateral approach and ZimmerBiomet ALPS plate surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Calcaneal fracture: fixation with extended lateral approach and ZimmerBiomet ALPS plate surgical procedure.
    Calcaneal fractures account for 1-2% of all fractures. They generally result from high energy mechanisms, most commonly falls from heights or road traffic accidents. The ‘rule of 10’ is useful when assessing these injuries, approximately 10% are bilateral, 10% open injuries and 10% associated with spinal injuries, usually thoracic-lumbar burst fractures.
    They are in the main very significant injuries when intra-articular in nature, and require a clear understanding of the fracture anatomy, and patient factors (most importantly compliance and avoidance of smoking) as well as what can be realistically achieved with operative techniques, when forming an opinion and counselling patients on how to be treated.
    Controversy surrounds their management, in particular whether open reduction and internal fixation is ever warranted, given a not inconsequential incidence of complications related to open approaches such as with the extended lateral approach described in some series. Such complications include wound breakdown, deep infection and pain syndromes related to cutaneous nerve compromise. This has led to the development of less invasive techniques to reconstruct calcaneal fractures including sinus tarsi approaches and percutaneous techniques.
    The extended lateral approach affords excellent visualisation of the components of the injury that require reduction, namely the lateral wall, subatalar and Calcaneo-cuboid joints and peroneal tendons. It is based one the angiosome of the lateral calcaneal artery, a terminal branch of the peroneal artery. The use of the extended lateral approach was popularised by, amongst others, Professor Roger Atkins at The Bristol Royal Infirmary, UK. His two seminal papers from 1993, published in the British Journal of Bone and Joint Surgery (and available open access), describe the patho-anatomy, surgical approach and sequence of fixation. They are essential reading for anyone embarking on the surgical fixation of articular depression fractures of the calcaneum, regardless of approach used.
    The UK heel fracture and its accompanying headline in the BMJ caused significant controversy with its assertion that open reduction and internal fixation should not be recommended for displaced intra-articular fractures. The debate over this paper continues but it is certainly true that newer techniques and implants continue to develop which avoid the need for the use of the extended lateral approach. It is also true that these fractures should be managed by surgeons and units used to dealing with large volumes of these injuries- the median number of operations per surgeon in the study was 2 and this may be related to the high rate of complications specifically a 19% infection rate which any surgeon or unit would deem unacceptable. As with many aspects of complex trauma, rather than didactically deciding on treatment based on a simple radiological review, the decision making as to the best treatment for an individual patient relies on careful examination of the injured limb, study of the X-rays and scans and a detailed discussion with the patient as to the risks and benefits of each treatment for them in light of other factors such as smoking or medical comorbidities- unfortunately this nuanced process does not lend itself to an RCT.
    In this case I have used the Zimmer-Biomet ALPS plating system. I prefer these implants when fixing calcaneal fractures with an extended lateral approach. The instrumentation is well designed, there are good screw options including cortical, locking and variable angle screws and crucially the plate and screws have a very low profile once the fixation is completed minimising the risk of soft tissue irritation or impingement.
    Readers will also find the following OrthOracle operative techniques of interest:
    Percutaneous fixation of Tongue-type calcaneal fracture
    Calcaneal fracture fixation : Internal fixation of sustentaculum tali fracture (Acutrak screws)
    Calcaneal fracture fixation: Extended lateral approach and locking plate fixation

    Indications

    INDICATIONS
    The indications for surgery in calcaneal fractures are those with displaced (>2mm) intra-articular fractures, significant loss of calcaneal height and heel widening, as assessed on imaging as below, and those with open fractures.
    SYMPTOMS & EXAMINATION
    Patients present with hindfoot pain and swelling following a high energy injury, most commonly a fall from height. Initial management should follow ATLS/ETC principles with a focus on excluding associated life or limb threatening injuries. Commonly associated injuries include spinal fractures, pelvic injuries and lower limb fractures associated with axial loads such as tibial plateau fractures. The history should include details of injury mechanism, patient co-morbidities and smoking status.
    Physical examination of the injured limb involves assessing for open injuries, documenting the neurovascular status and a careful assessment of the soft tissues. The contralateral limb should be assessed to exclude bilateral injuries. Compartment syndrome should also be excluded however decompression of the foot is a controversial area with many surgeons preferring to avoid fasciotomies of the foot as the sequelae of multi-incision fasciotomy (need for plastics reconstruction, risk of deep infection) is often worse than the sequelae of the compartment syndrome itself (claw toes). Personally I would only consider fasciotomy if the patient’s pain could not be controlled or there was clear neurological compromise (ie need for acute tarsal tunnel decompression). Another option to decompress the foot is ‘pie-crusting’ where multiple stab incisions are made to decompress myofascial compartments- this avoids large incisions and does not compromise future reconstruction.
    IMAGING
    Imaging includes plain X-rays (AP & Lateral ankle and axial calcaneal views) plus CT scanning. Understanding the imaging is key to deciding whether a fracture is improvable, in the context of other patient factors
    From the plain radiographs it possible to classify according to the Essex-Lopresti system (centro-lateral displacement versus tongue-type) and to assess the amount of heel varus and therefore widening as well as the calcaneal height. Bohlers angle describes the angle subtended between a line from the superior anterior process and highest point of the posterior facet and a second line along the superior edge of the tuberosity. Normal values are between 20-40 degrees, values less than 20% indicate a compression of the posterior facet and consequent loss of calceneal height.
    The CT is the key to understanding the anatomy of the injury. Time should be spent reviewing the differing planes to build a image of the injury in ones mind. The key features to assess are:
    Heel varus/medial wall: Correcting this is the first stage of reconstruction.
    Joint surface: The number of articular fragments, position and displacement (see Sanders classification below).
    The state & position of the sustentaculum: The so called constant fragment onto which traditionally the remainder of the calcaneum is built during reconstruction. If this fragment is too comminuted the fracture may be considered non-reconstructable.
    The lateral wall: If using an extended lateral or sinus tarsi approach one needs to plan how the lateral wall will be addressed to access the joint surface- can it be mobilised, will it need osteotomising, is it attached to an articular fragment?
    The calcaneocuboid joint, there is generally a split running anteriorlly into the calc-cuboid joint. the final part of reconstruction is to reattach the tuberosity, body and anterior calcaneum to each other.
    Position of the peroneal tendons: These may be dislocated (up to 30%), which can be evident on the CT, in which case they will need to be reduced and stabilised at the end of the procedure.
    The Sanders’ CT classification.
    The most commonly used classification system of displaced intra-articular calcaneal fractures is that of Sanders, based on a semi-coronal CT scan in the plane of the posterior facet. Primary fracture lines are described in the posterior facet (A- most lateral, to C- most medial). Fractures are then classified by the number of fracture lines in the posterior facet and their position. Type 1 fractures are those with less than 2mm displacement of articular fragments regardless of number of fragments. Type 2 fractures have 1 fracture line and 2 articular fragments and can be described as 2A, 2B or 2C depending on the position to fracture line. Type 3 fractures have 2 fracture lines in the posterior facet with 3 articular fragments and are described as 3AB, 3AC or 3BC. Type 4 fractures have 3 fracture lines and 4 articular fragments. Sanders 1 fractures generally do not need fixing, Sanders 2 should be considered for fixation with either an extended lateral or sinus tarsi approach depending on the other components of the injury (eg whether varus/medial wall can be reconstructed with a sinus tarsi approach). Sanders 3 injuries can again be considered for surgical fixation but are likely to need an extended lateral approach owing to the extent of the articular injury. Sanders 4 injuries may not be reconstructable although surgery to reconstruct the overall heel shape (height/width) or even primary fusion may be options.
    Essex-Lopresti classification
    An alternative classification system is that of Essex-Lopresti. His paper on calcaneal fracture was published posthumously and divided intra-articular calcaneal fractures into undisplayed (15%), centro-lateral displacement (32.8%), gross comminution (21.5%), isolated sustentaculum (0.4%) or tongue type (19.9%). The tongue type fracture occurs when the displaced articular fragment remains attached to the tuberosity. Essex-Lopresti described a reduction technique with a Gissane spike introduced percutaneously which was then incorporated into a plaster.
    Atkins Classification
    A classification of the fracture anatomy specifically relating to the “lateral wall” of the calcaneus which is the aspect that first presents itself to the Surgeon approaching by a lateral approach, which is very useful and much under utilised. It is based on the coronal CT fracture pattern and if used helps understand how to effectively mobilise the lateral wall to expose the posterior facet and joint surface. This detail is all comprehensively covered in part 1 of the 2 key papers by Atkins et al, referenced and linked to below.
    Type 1: The lateral wall is formed soley from the lateral joint fragment
    Type 2: The lateral wall is formed from both the lateral joint and body fragment
    Type 3: The lateral wall is formed soley from the body fragment
    ALTERNATIVE OPERATIVE TREATMENT
    Surgical fixation of calcaneal fractures remains a controversial area and a should be discussed thoroughly with the patient before deciding on fixation. The aims of surgery are to correct the heel varus (and therefore restore heel width), restore the calcaneal height (corrects talar rotation, unlocks the Chopart joint complex, and prevents anterior ankle impingement) and articular congruity (restores the mechanics of the subtalar joint but does not reverse the damage to the articular surface). The most feared risks of surgery are infection or wound breakdown (reported in up to 20% of cases with extended lateral approaches) as well as the longer term risks of subtalar arthritis.
    The options for surgical treatment are:
    Fixation via the standard extended lateral approach, this affords excellent visualisation of the whole calcaneum and subtalar joint and I would use this when I am not confident of achieving adequate fracture reduction with other, less invasive, approaches. This approach also allows other components of the injury, such a peroneal tendon dislocations, to be addressed easily.
    The second option is a sinus tarsi approach, this has less risk of wound problems than an extended lateral approach but only affords limited access to the joint surface plus medial wall reduction and correction of varus are more challenging. There are now specific plates for use with sinus tarsi approaches. I would use this approach for more simple articular injuries (ie Sanders 2) and when I am confident that the medial wall can be reduced via the limited incision. This approach cannot be meaningfully extended so one needs to be sure of a good reduction via this more limited exposure before embarking on it.
    The final option is an entirely percutaneous approach, the tongue type fracture pattern in particular lends itself to this approach. Here it is possible to reduce the entire joint surface and achieve fixation via the same small incision. There is less heel varus with tongue type injuries and therefore medial wall reduction is less of a concern. In my hands significant heel varus or more extensive joint involvement would be contraindications to this technique and would need one of the open approaches above to reconstruct.
    NON-OPERATIVE MANAGEMENT
    Patients with extra-articular fractures, minimally displaced fractures (less than 2mm joint displacement, minimal loss of height or heel widening) can be managed non-operatively. Non-operative treatment should also be carefully considered in older patients, those with significant medical morbidities and smokers, especially if considering open approaches, due to the significant risks of wound problems in these groups. The risk of wound problems should not be underestimated, wound breakdown with deep infection is a limb threatening condition. Non-operative management consists of splinting the foot, normally in an aircast type boot, off-loading the foot (non-weight bear for the first 6 weeks if possible) and early mobilisation of the foot and ankle joints under physiotherapy supervision.
    CONTRAINDICATIONS
    I would not offer surgery in those unable , for whatever reason, to comply with post-operative instructions or patients with significant medical problems such as poorly controlled diabetes (either known complications such as neuropathy/retinopathy or raised HbA1C) and vascular disease.

    Intra-articular fractures of the Calcaneum. Part 1:Pathological anatomy & classification. Part 2: Open reduction and internal fixation by the extended lateral trans-calcaneal approach. J Bone Joint Surg (Br) 1993; 75-B 183-195.
    D. M. Eastwood, P.J.Gregg, V.G.Langkamer, R.M.Atkins. https://online.boneandjoint.org.uk/doi/abs/10.1302/0301-620X.75B2.8444934

    Setup

    Patients with unilateral injuries are positioned laterally, injured side up. For those undergoing fixation of bilateral injuries fixation of both feet can be performed with the patient in a prone position although I would prefer to perform surgery with the patient in a lateral position and turn them to fix the other limb. Consideration must be given to the patients other injuries (eg spinal stability) when positioning them. The patient should be positioned on the operating table such that the feet are at the end of the table to allow good lateral and axial imaging intra-operatively.
    Intravenous antibiotics are given at induction of anaesthesia. If the other limb is uninjured then a TED stocking and flowtron boot should be placed on this limb. In general I do not like to use tourniquets for lower limb trauma surgery owing to the difficulties associated with their use, particularly adding further ischaemia to already traumatised tissues however I do find a tourniquet invaluable when fixing calcaneal fractures with an extended lateral approach due to the continuous ooze of blood one otherwise encounters.

    Operation – 1

    Lateral X-ray shows a displaced intra-articular fracture.
    There is loss of calcaneal height and shortening. The joint surface is poorly visualised but a significantly depressed fragment is seen (1.)

    The axial X-ray shows the medial wall disruption and heel varus (1.).
    The lateral wall is bulged (2.) and there are there is significant depression of a large articular fragment (3.).

    Sagittal CT confirms the X-ray findings and shows complete separation of the tuberosity and body fragments.

    Semi-coronal CT suggests 2 primary fracture lines in the posterior facet (1., Sanders 3).
    Part of the joint surface remains attached to the lateral wall of the calcaneum which has rotated into valgus (2., Atkins Type 1).

    The patient is placed in a lateral position.The foot is at the end of the table to allow good access for image intensifier.

    The skin incision runs from the tip of the 5th metatarsal along the junction of plantar and dorsal skin, angling vertically towards the Achilles at the point of the heel and staying just anterior to the tendonThe skin incision is as drawn, the lateral malleolus (1.) and base of 5th metatarsal (2.) are marked. Note the lower, horizontal limb (3.) is at the junction of the glabrous skin of the sole and the normal skin of the lateral aspect. The commonest error is for this part of the incision to be made too proximal. This violates the angiosome of the lateral calcaneal artery and compromises skin healing of the wound. In my opinion it is this which leads to the high incidence of wound problems reported by some authors and the bad reputation that this approach has in some eyes.
    The vertical limb creates an approximate 100 degree angle with the horizontal limb and extends proximally just anterior to the achilles tendon, thus avoiding injury to the calcaneal branch of the peroneal artery, to just proximal to the level of the lateral malleolus. The sural nerve is elevated within the flap but can be at risk in the proximal part of the incision.

    After the skin incision, sharp dissection is made straight to bone at the junction of the horizontal and vertical limbs.This allows a full thickness skin flap to be raised with no undermining of the skin. Note skin edges are gently retracted without crushing of the tissues, similarly self retaining retractors are not used to avoid unnecessary tissue damage.

    A full thickness flap is elevated from the lateral wall of the calcaneum with sharp subperiosteal dissection, extending first anteriorly to calcaneo-cuboid joint.The sural nerve is at risk in the proximal part of the vertical limb and distal part of the horizontal limb – careful dissection with tenotomy scissors is carried out here although I do not actively seek to expose or identify the nerve.
    As the flap is elevated from the lateral wall the peroneal tendons are encountered and are lifted off the lateral wall remaining within the skin flap, occasionally they will need to be mobilised from the trochlea on the lateral wall.
    In up to 30% of cases the tendons have dislocated from the fibula groove and sit anterolaterally over the fibula- this may be apparent on the pre-op CT and can be confirmed at this stage. If they are dislocated stabilisation will be required at the end of the procedure.

    The subperiosteal dissection is continued posteriorly to The flap is elevated from the lateral wall of the calcaneum. Eventually a triangular flap is formed with a long axis joining the horizontal and vertical limbs and crossing the subtalar joint.
    Dissection from bone continues until the subtalar joint superiorly (as shown with forceps) and the calcaneo-cuboid joint distally are exposed.
    Exposure of the subtalar joint requires elevation of the calcaneo-fibular ligament, inversion of the hindfoot by placing a rolled up Huck towel beneath the medial malleolus then helps to visualise the subtalar joint.
    Distally the calcaneo-cuboid joint is identified by following and elevating the peroneal tendons as they run distally within the skin flap.

    2 K-wires are placed to self-retract the skin flap, one in the distal fibula and one from lateral into the talar neck.

    Once the K-wires are placed and drilled they are bent back on themselves to retract the soft tissue flap.2mm K-wires are used. The first is placed in the fibula, the tip of the fibula sits in the surgical field just above the posterior facet, the wire entry point is on the tip of the fibula and the wire is then driven along the long axis of the fibula to engage the medial cortex (1.).
    The second wire is placed more anteriorly, in the talus, the talar neck can usually be identified by palpation with the tip of the wire, the wire is then driven into place transversely across the talar neck to engage 2 cortices. Once good purchase in bone is confirmed the wire ends are bent by grasping the wire in the driver close to bone (2.). This allows gentle retraction of the flap during surgery and affords good exposure of the whole lateral calcaneum and the posterior facet without the need for further retraction.

    The lateral wall of the calcaneum is disimpacted and mobilised to access the posterior facet.This is an Atkins type 1 with part of the articular surface attached to the lateral wall. Lambotts osteotomes are used to develop the existing fracture lines in the bulged lateral wall (1.) to allow the segment with the articular surface attached to be mobilised. Inferiorly the lateral wall mobilisation is continued by formal osteotomy (2.).
    The whole lateral wall fragment together with the attached articular fragment can now be gently lifted to expose the posterior facet and depressed articular fragments beneath.

    The lateral wall fragment with articular surface can now be seen (1.), I have kept the posterior part attached to the calcaneum to allow it to hinge. The posterior facet of the calcaneum is now clearly visible (2.) as is the inferior surface of the talus (3.).

    The lateral wall fragment can now be wrapped in a damp swab and moved out of the surgical field while keeping the posterior hinge intact.This can be kept in place with a few skin clips- I believe this is the only indication for use of skin clips in trauma surgery.

    If the medial wall needs to be reduced, which is not always the case, it is accessed through the primary fracture line, once the lateral wall has been reflected.A periosteal elevator or a Howarth (as here) is carefully advanced along the primary fracture line so that it sits between the sustentaculum and the body of the calcaneum, (the direction is shown in the CT slice on the next slide) .

    The elevator is then used firstly to gently disimpact and mobilise the body. Next the body is reduced onto the sustentacular fragment by hooking the instrument beneath the sustentaculum and gently levering the body into position and thus restoring the medial wall.Coronal CT showing the position of the primary fracture line, an elevator is passed along the line shown to allow medial wall reduction.
    The sustentaculum (1.) is generally considered as a constant fragment which normally sits in its anatomical position and onto which the rest of the calcaneum can be built during reconstruction.
    In this case it needs to be angulated back to its normal position.
    The FHL tendon and neurovascular bundle run beneath the sustentaculum and care must be taken to avoid penetrating too deeply with the elevator and injuring these structures.

    The medial wall reduction and heel varus are held corrected while a 2mm k-wire (2.) is inserted from the heel into the body fragment, the entry point is at the midpoint medial-lateral and posterior in the body.Note that the elevator is held in my left thumb and is maintaining the body reduced on the sustentaculum, while the hand is grasping the body to correct the varus.
    The wire is then directed medially and anteriorly to pass along the medial side of the calcaneum and engage the sustentaculum- this wire can be driven into the talus for extra hold.
    Once the wire is positioned the position and reduction are confirmed on lateral and axial images (as below) I find this the hardest stage of the reconstruction and I often need several attempts to get a satisfactory reduction.

    The medial wall reduction is confirmed with an axial X-ray following K wire stabilisation.This is performed by moving the c-arm into a horizontal position and holding the foot, still in a lateral position, at 45 degrees to the beam- this way the foot does not need to be rotated to get a good image.

    The k-wire can be seen holding the medial wall reduction (1.) and engaging the sustentaculum (2.).

    The posterior facet is re-approximated and held with K-wiresThis is a Sanders 3 injury. The central piece was significantly depressed and within the body of the calcaneum. This was mobilised and retrieved as a separate, loose fragment. I have then built this onto the lateral wall articular fragment (1.) and held this with a 1.6mm k-wire.

    The reconstituted lateral wall and central articular fragment is then reduced en-masse onto the remaining sustentacular fragment (the so called constant fragment) and held with a k-wire (1.). The undersurface of the talus can be used as a template to guide the reduction, the k-wire should be positioned away from the site of the lag screw that will be inserted later to fix the joint surface.

    The reduction is first checked under direct vision, which is easier when looking from behind and gaining a view down the posterior facet rather than looking from the lateral side and across.

    The reduction is then confirmed radiologically with lateral and axial views to confirm that the posterior facet and calcaneal height have been restored. The plantar surface remains incongruent. This does not require an anatomical reduction but does suggest some shortening of the calcaneum which will be addressed later.

    The axial image confirms that the articular fragments (1.) have been reduced onto the sustentaculum (2.).

    The articular fragments are now fixed onto the sustentaculum using a 3.5mm cortical screw from the ALPS set.The entry point is in the lateral wall, approximately 5 mm beneath the posterior facet joint surface. The drill is aimed toward the sustentaculum, which can be palpated on the medial side of the foot. The screw will sit beneath the footprint of the plate but can be sunk a little and does not interfere with positioning of the plate.
    First identify the large medial prominence of the navicular, move your finger directly backwards and the next, smaller, prominence one palpates is the sustentaculum. As a rule the drill is generally directed 10 degrees forward and 10 degrees cephalad.
    I tend to drill first with a 2.5mm drill bit into the sustentaculum then overdrill the near fragments with a 3.5mm drill bit so that the screw lags and compresses the joint surface.

    Operation – 2

    The screw is tightened in place, it should measure 40-45mm, anything less suggests it is not in the sustentaculum.

    The Lag screw position is checked on lateral imaging.

    On the axial view correct positioning in the sustentaculum is confirmed (1.)
    If the screw is too low the FHL and the neurovascular bundle are at risk.

    Here I using the Zimmer-Biomet ALPS set. The calcaneal plates are on the left (1.).
    I prefer these implants as they give good fixation options and contour well to the bone as fixation proceeds to give a low profile implant with minimal risk of symptomatic metalwork. The tray also contains various midfoot plates (2.) and plate benders (3.) which are not normally needed as the plate will contour as the screws are tightened into place.

    The calcaneal plates come in large or small sizes and, for non-colour blind surgeons, are helpfully colour coded, Lime for Left and Rose for Right.
    The plates are titanium and are anatomically shaped for the lateral calcaneum with multiple screw options.
    The plates come loaded with drill guides in the screw holes (1) for placing locking screws but each hole can take either a cortical, a locking or a variable angle locking screw. I tend to use all cortical screws and either use the guide or remove before drilling depending on how I want to place the screw to capture good bone.

    The implant is positioned on the lateral calcaneum and provisionally fixed in place with 2 k-wires.It is positioned to avoid impinging on the talus or fibula and to allow at least 2 screws in each segment (tuberosity, body, anterior process), I also avoid having metalwork directly beneath the wound edges.

    As the final part of the reduction a small clamp is applied around the plate to reconstruct the Angle of Gissane and the plantar aspect of the calcaneum.
    The anterior part of the Angle of Gissane is often pulled superiorly and one tine of the clamp is placed on this fragment, the other tine of the clamp is placed on the plantar part of the calcaneum. This plantar aspect was shown malreduced on the previous II image.
    The clamp is gently tightened (the bone is relatively soft) and the Angle of Gissane is restored, together with the plantar surface. At times the clamp gets in the way of the plate and can be replaced with a 1.6mm k-wire.

    The plate position is checked on lateral imaging.The plate will be used to join the tuberosity (1.), the body (2.) and the anterior process (3.) and I aim to place at least 2 screws in each segment.
    The ALPS system has options for fixed angle locking screws, variable angle locking screws and cortical screws.
    In my experience cortical screws can be used in nearly all situations- if the bone stock is so poor that locking screws are needed then fixation may not have been the best option for that patient!

    Once reduction of the angle of Gissane and the rest of the fracture is confirmed plate fixation proceeds.A 2.5mm drill bit is used to drill for a 3.5mm cortical screw, the screw-in guide can be removed from the plate before drilling as we are placing cortical screws and this will allow more freedom in directing the screws to good bone- this is particularly important anteriorly where one must take care to avoid placing screws in the fracture lines that run forwards toward the calcaneo-cuboid joint.

    I tend to fix a screw into each segment initially and then add screws as needed after that to ensure each segment has at least 2 screws and that the plate has been pulled onto the bone and therefore won’t impinge or irritate. The body and tuberosity have good bone stock and should have good purchase for cortical screws. It can be harder to get good hold in the anterior process although this is normally possible if one takes care to avoid the fracture lines, if good hold really isn’t possible then a locking screw may be indicated.

    Once the screws are all tightened in the plate sits well on the bone.

    Final lateral xray confirms that calcaneal height has been restored.

    A Broden view (AP image beam with ankle 30-45 degree internally rotated) confirms that the posterior facet has been restored.

    Axial views confirms the medial wall reduction and restoration of heel width, as well as ensuring no medial prominence of the screws.

    Before closure the peroneal tendons should be checked to ensure they sit in the fibula groove.If they are dislocated they should be stabilised by reducing them and reconstructing the retinaculum. I use a small drain beneath the flap to avoid any haematoma formation. Closure is done in layers, I use a 2/0 vicryl interrupted subdermal suture.

    Following subdermal closure the skin edges should be well opposed with no tension.

    The skin is closed with interuppted nylon using with either a horizontal mattress or an Allgower-Donati suture.

    As with all foot and ankle surgery, non-adhesive dressings should be used.

    A below knee backslab is applied to keep the ankle in a neutral position and rest the soft tissues.

    Post Operative

    Post-operatively the should be kept elevated. The drain is removed at 24 hours. Patients mobilise non-weight bearing for the first 6 weeks and then progress weight bearing over the next 6 weeks with an aim to be fully weight bearing by 12 weeks. VTE prophylaxis with low molecular weight heparin should be given for 6 weeks in total as per NICE guidelines.
    I review patients in clinic at 2 weeks to ensure the wound has healed satisfactorily, at this point the plaster is removed and the patient can go into an aircast boot (assuming no soft tissue problems- I prefer a plaster until wound healing as boots tend to be less forgiving on the soft tissues than a well-moulded plaster). Physiotherapy to mobilise the ankle and hind foot also begin at 2 weeks.
    Patients should be warned at the outset that recovery from these injuries will take 2 years regardless of treatment, I generally follow patients up for at least 12 months to ensure no early complications.

    Recommended Reading

    Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res. 1993;290:87-95.
    This paper describes the Sanders classification outlined above. It is also unusual among published work in that a clear learning curve is described with outcomes improving with surgeon experience for Sanders 2 and 3 fracture patterns (but not for Sanders 4 injuries).
    Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res. 1993;290:87-95.
    This paper describes the Sanders classification outlined above. It is also unusual among published work in that a clear learning curve is described with outcomes improving with surgeon experience for Sanders 2 and 3 fracture patterns (but not for Sanders 4 injuries).

    DM Eastwood, PJ Gregg, RM Atkins. Intra-articular fractures of the calcaneum. Part I: Pathological anatomy and classification. The Journal of Bone and Joint Surgery. British volumeVol. 75-B, No. 2
    D M Eastwood 1 , V G Langkamer, R M Atkins. Intra-articular fractures of the calcaneum. Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach. J Bone Joint Surg Br. 1993 Mar;75(2):189-95. doi: 10.1302/0301-620X.75B2.8444935.
    These two papers are essential reading for anyone fixing calcaneal fractures. In the first paper the path-aantomy of displaced intra-articular calcaneal fractures is described together with a classification of the lateral wall injury which helps determine the approach to the joint. The second paper outlines the sequence of fixation to reconstruct these injuries, as outlined above. Although the focus is on fixation with an extended lateral approach the sequence described should be followed with other approaches such as the sinus tarsi approach.
    Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg. 1952;39:395-419.
    This paper, published posthumously, outlines a classification system for calcaneal fractures (based on plain radiographs) as well as the treatment of each type including treatment of tongue type injuries with a Gissane spike incorporated in a plaster. Although the outcome scores are rudimentary the importance of achieving a good articular reduction is emphasised.
    Damian Griffin, , Nick Parsons, , Ewart Shaw, associate professor in statistics, Yuri Kulikov, , Charles Hutchinson, , Margaret Thorogood, , Sarah E Lamb. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial
    BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4483 (Published 24 July 2014)
    The UK heel fracture study randomised patients with displaced intra-articular fractures to operative or non-operative surgery. Surgery was performed via an extended lateral approach. The controversial conclusion was that surgery should not be offered for these fractures, this was accompanied by a front page cover of the BMJ stating that “Calcaneal fractures: Surgery provides no benefits.” This resulted in significant controversy, among the criticisms of the paper and the accompanying headline was the low number of included patients (151 randomised from 502 eligible) and the seeming limited experience of the operating surgeons (median 2 operations per surgeon during the trial).

    Journal Foot and Ankle Surgery. VOLUME 55, ISSUE 4, P821-828, JULY 01, 2016 https://doi.org/10.1053/j.jfas.2016.01.035
    Operative Versus Nonoperative Treatment for Displaced Intra-Articular Calcaneal Fractures: A Meta-Analysis of Randomized Controlled TrialsXiangping Luo, MD, Qi Li, MD , Shengmao He, PhD, Shunqing He, MD
    Meta-Analysis of randomised studies assessing calcaneal fixation versus non-operative treatment (including the UK heel fracture study). Patients undergoing surgery had a higher risk of complications and there was no significant difference in functional scores between the two groups, however non-operatively treated patients had statistically significant higher rates of chronic pain, poor shoe fitting and later subtalar arthrodesis.
    Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg. 1952;39:395-419.
    This paper, published posthumously, outlines a classification system for calcaneal fractures (based on plain radiographs) as well as the treatment of each type including treatment of tongue type injuries with a Gissane spike incorporated in a plaster. Although the outcome scores are rudimentary the importance of achieving a good articular reduction is emphasised.
    Damian Griffin, , Nick Parsons, , Ewart Shaw, associate professor in statistics, Yuri Kulikov, , Charles Hutchinson, , Margaret Thorogood, , Sarah E Lamb. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial
    BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4483 (Published 24 July 2014)
    The UK heel fracture study randomised patients with displaced intra-articular fractures to operative or non-operative surgery. Surgery was performed via an extended lateral approach. The controversial conclusion was that surgery should not be offered for these fractures, this was accompanied by a front page cover of the BMJ stating that “Calcaneal fractures: Surgery provides no benefits.” This resulted in significant controversy, among the criticisms of the paper and the accompanying headline was the low number of included patients (151 randomised from 502 eligible) and the seeming limited experience of the operating surgeons (median 2 operations per surgeon during the trial).

    Journal Foot and Ankle Surgery. VOLUME 55, ISSUE 4, P821-828, JULY 01, 2016 https://doi.org/10.1053/j.jfas.2016.01.035
    Operative Versus Nonoperative Treatment for Displaced Intra-Articular Calcaneal Fractures: A Meta-Analysis of Randomized Controlled TrialsXiangping Luo, MD, Qi Li, MD , Shengmao He, PhD, Shunqing He, MD
    Meta-Analysis of randomised studies assessing calcaneal fixation versus non-operative treatment (including the UK heel fracture study). Patients undergoing surgery had a higher risk of complications and there was no significant difference in functional scores between the two groups, however non-operatively treated patients had statistically significant higher rates of chronic pain, poor shoe fitting and later subtalar arthrodesis.

    Reference

    • orthoracle.com

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