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Calcaneal fracture- Percutaneous fixation of Tongue-type fracture

    Overview

    Learn the Calcaneal fracture: Percutaneous fixation of Tongue-type fracture 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: Percutaneous fixation of Tongue-type fracture surgical procedure.
    Calcaneal fractures account for 1-2% of all fractures. They generally following high energy mechanisms, most commonly falls from height 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 on how to manage.
    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 described in some series, such as 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.
    Overall tongue type calcaneal fractures tend to have a more favourable prognosis when compared to articular depression patterns and perhaps not surprisingly treating these injuries with percutaneous techniques also offers advantage. A recent retrospective cohort study by Quirine showed a lower incidence of wound problems and deep infection when tongue type fractures are managed with percutaneous compared to open techniques.
    In essence the technique was first described by Peter Essex-Lopresti, one of the Worlds first dedicated Orthopaedic trauma Surgeons. He practiced at the Birmingham Accident Hospital, the Worlds first dedicated trauma centre, before dying at the tragically young age of 35. His work was based on observations made treating the Sixth British Airborne Division, in World War II, and is a significant landmark in improving the lives of patients with these injuries. In addition to describing the patterns of calcaneal fractures and the percutaneous technique for fixation of tongue type fractures his paper also describes a sinus tarsi approach to articular depression fractures.
    The UK heel fracture trial and its accompanying headline “Calcaneal fractures: surgery provides no benefits” in the British Medical Journal(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 traditional open surgery, and are associated with a lower immediate incidence of complications.
    It is also true that these fractures should be managed by surgeons and units used to dealing with large volumes of these injuries. This has been recognised for some time, and indeed was specifically reported on in 2008 by Poeze, and this is really only common sense. The median number of operations per surgeon in the BMJ study was 2 and this itself may be related to the high rate of complications, specifically a 19% infection rate, which any surgeon 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 of 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 co-morbidities. Unfortunately this patient-centred process does not lend itself to an RCT.
    Readers will also find of interest the following related OrthOracle techniques:
    Calcaneal fracture fixation : Internal fixation of sustentaculum tali fracture
    Calcaneal fracture fixation: Extended lateral approach and locking plate fixation

    Quirine M J van der Vliet 1 , Jeffrey M Potter 2 , Thirza A Esselink 3 , Roderick M Houwert 4 , Falco Hietbrink 4 , Luke P H Leenen 5 , Marilyn Heng. Open Versus Closed Operative Treatment for Tongue-Type Calcaneal Fractures: Case Series and Literature Review. J Foot Ankle Surg . Mar-Apr 2020;59(2):264-268. doi: 10.1053/j.jfas.2019.02.006.
    Poetze M, Verbruggen J, Brink P. The relationship between the outcome of operatively treated calcaneal fractures and institutional fracture load: A systematic review of the literature. The Journal of Bone and Joint Surgery (Am). 2008. 1013-20.
    Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M, Lamb S. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised, controlled trial. The British Medical Journal. 2nd August 2014.

    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 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 higher 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% represent collapse 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:
    1. Heel varus: Correcting this is the first stage of reconstruction.
    2. Joint surface: The number of articular fragments, position and displacement (see Sanders classification below).
    3. 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.
    4. 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?
    5. 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.
    6. 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 articaulr 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.
    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 as demonstrated below. There is less heel varus with tongue type injuries and therefore medial wall reduction is less of a concern. In my hands significant heel various 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.

    Setup

    Patients with unilateral injuries are placed in a lateral position, injured side facing up, with appropriate bolsters. The feet should be positioned right at the end of the table. In bilateral cases the options are to either operate in a lateral position and move the patient to operate on the other foot or to place the patient in a prone position which allows access to both heels.
    Patients are given intravenous antibiotics pre-operatively. I do not generally use a tourniquet for trauma cases to avoid further iscahemic insult to injured tissues but do find it makes calcaneal fixation via an extended lateral approach significantly easier due to the constant ooze one otherwise encounters- tourniquets are not needed for sinus tarsi or percutaneous approaches.
    The foot has a social scrub before prepping and draping. During surgery the injured leg is placed behind the good leg, I find that placing a bolster such as a gown pack underneath the injured leg helps with imaging.

    Operation – 1

    Lateral X-ray of a polytrauma patient with bilateral calcaneal fractures.
    On this side there is a tongue-type intra-articular fracture. It can be seen that the displaced articular fragment (1.) remains attached to the tuberosity which has rotated producing a posterior ‘bossing’ (2.)- in severe cases this can threaten the integrity of the posterior soft tissues.

    The axial view shows that alignment remains satisfactory.
    There is a mild bulging of the lateral wall(1) but minimal medial wall disruption.

    The sagittal CT shows a 3mm displacement of the posterior facet.
    One could certainly make a case for managing this injury non-operatively, this was discussed with the patient and in view of his bilateral injuries we decided to proceed with percutaneous fixation.

    Semi-coronal CT shows that the medial wall is largely intact, and the sustentaculum undisplacd(1), with minimal heel varus.

    The patient is positioned in a lateral position, bad side up.The foot is at the end of the table with the knee flexed. A “social scrub” is performed, before full surgical preparation of the limb.

    With the limb thus positioned lateral imaging is easily achieved.Axial imaging is performed by moving the intensifier arm into a ‘shoot through’ position (ie horizontal beam) at 45 degrees to the plane of the foot, this affords a good view of the medial wall, sustentaculum and posterior facet.

    A bolster is placed beneath the injured foot and the uninjured side placed behind the injured side to allow good quality imaging.To begin the site of the incision is marked using the image intensifier in a lateral position.


    The incision should be over the posterior part of the tuberosity fragment.

    The site of the incision is shown on this CT cut as a black line, 1.
    The incision is positioned just lateral to the achilles tendon and situated to allow access to the tongue fragment.

    A 15mm longtitudonal incision is made, this would be part of the vertical limb of an extended lateral approach, thereby allowing safe extension if required.After skin is incised blunt dissection with scissors proceeds through the fat layer straight down to bone. The sural nerve is at risk but should be anterior to the incision. The nerve runs with the short saphenous vein between the lateral malleolus and achilles tendon.
    Posteriorally it is important to stay out of the peritendinous covering of the achilles tendon, breaching this will result in persistent wound leakage post-operatively.




    Next a 5mm schanz pin (150mm length, 50mm thread, 1.) is mounted on a universal chuck (2.).The pin is then placed through the incision onto the tuberosity fragment and the position checked with the image intensifier.
    The entry point should be as close to the medio-lateral midline as possible but tends to be lateralised by the Achilles tendon.
    An assistant to steady the foot is helpful as the pin is engaged in the bone.

    The schanz pin should be positioned at the poster-superior corner of the tuberosity.It should de directed beneath the posterior facet aiming to a point just inferior to the Angle of Gissane (1.).
    The pin will inevitably run slightly postero-lateral to antero-medial owning to the entry point being lateral but as much as possible should remain central within the tuberosity fragment. It should be possible to ascertain that the pin is in bone by feel alone but if there is doubt an axial X-ray should be taken.

    The shanz pin is advanced anteriorly, directed beneath the posterior facet aiming to a point just inferior to the Angle of Gissane, carefully paying attention to the position on imaging and the skin edges.

    The pin is advanced all the way beneath the posterior facet fragment under X-ray control.There should be a feel of good, solid, bone, as the pin advances.
    I do not routinely use an axial image at this point, care should be taken that the pin is not directed too far medially but it is possible to feel clinically that the pin remains in bone.

    The reduction manœuvre is now performed, with one hand on the chuck and one on the forefoot, both hands are pulled down the distal end of the pin is elevated and the posterior facet fragment is reduced onto the talus.This is a modification of that described by Essex-Lopresti. One hand grasps the forefoot (1.) and the other holds the pin/chuck (2.). Both hands are pulled down and towards each other within the longitudinal plane of the foot.
    There is usually a satisfying click as reduction is achieved. The posterior facet is being reduced onto the talus which provides a template for reduction and makes over-reduction unlikely. Reduction is certainly easier if surgery is performed within the first few days of injury but good reduction is still possible up to 10-12 days after injury in our experience.

    The reduction is checked on image intensifier.The posterior facet and calcaneal height should be seen to be restored. As noted above there is little medial wall disruption with this fracture pattern and I do not routinely check an axial image at this stage as the reduction is generally complete once the posterior facet is reduced and calcaneal height restored and these injuries generally do not have significant associated medial wall disruption/varus- as noted above injuries that do have significant varus are likely to be better managed with open techniques.

    Here I am using the Matta screw set (Stryker), normally part of the pelvic instruments.These include 3.5mm cortical screws. I prefer to use solid screws rather than cannulated as the screws are stronger and I do not feel that cannulated screws are necessary, I have not found that larger screw diameters are needed. This set has the advantage that the instruments come in longer sizes and a good range of longer screw options are available.
    These are standard self-tapping cortical screws. They are used primarily in a position/raft mode and washers are therefore not needed.

    While an assistant holds the reduction the screw guide is positioned via the original incision and above the pin (1.)

    The position of the drill guide is checked on image intensifier.This screw will pass from the tuberosity fragment to the anterior process and act to ‘raft’ the posterior facet.

    The position of the drill guide is checked on image intensifier. and the first the 2.5mm drill is passed.The drill may impinge on the Schanz pin in which case the medio-lateral trajectory may need to be fine-tuned to bypass the pin.

    Following drilling the depth gauge is inserted along the screw tract.Careful attention should be paid to accurate measurement of screw length, I would generally check that the depth gauge is properly positioned in the screw tract and the gauge seated on bone with the image intensifier. If the screw is too short it will not provide sufficient support, if too long it will impinge on the calcaneo-cuboid joint.

    A self tapping 3.5mm cortical screw is then inserted, and its position confirmed on imagingCare needs to be taken at this point that the drill tract is not lost.
    Only remove the depth gauge once the screws is in hand and pay careful attention to the position and orientation of the depth gauge in the bone to avoid disappointment!
    Changing the screw, if the wrong size has been selected, is possible but somewhat awkward hence the need for care is measuring screw size as noted previously.

    Screw position is confirmed on imaging, good purchase is generally achieved.This screw is passing from the tuberosity, beneath the posterior facet and angle of Gissane, to the anterior process.
    It acts to support the Tongue fragment.

    The process is now repeated to place a second screw from the tuberosisty into the anterior process, this screw is more or less (less in this case) parallel with the first, but need not be.Space is limited by the Schanz pin and the first screw but it is generally possible to find a good entry point for this second screw, inferior to the original screw entry point, within the confines of the incision.

    This screw is again directed from the posterior tuberosity fragment, passing beneath the posterior facet and engaging the anterior process.As with the first screw it serves to raft and support the posterior facet.

    Operation – 2

    A third screw is now placed from the tuberosity into the calcaneal body, and checked on X-Ray.This screw can be inserted via the same incision. In most cases these three screws are sufficient.
    If there is doubt regarding stability a fourth screw can be added that passes from lateral to medial via a seperate incision and fixes the posterior facet fragment to the sustentaculum tali (as one would use with an extended lateral approach).

    The axial view X-ray is also checked.Here the inferior screw (1.) is too far medial and at risk of irritating the structures running beneath the sustentaculum tali (FHL, neurovascular bundle, 2.). This screw was therefore repositioned.

    Final lateral xray, the calcaneal height has been restored and the posterior facet appears congruent.

    Final axial view, following exchange of medial screw.

    The incision is closed in layers.I use a 2/0 vicryl sub-dermal layer and an interrupted nylon stitch to skin.

    The resulting scar is very small and not directly over the Achilles, so tends not to rub in shoewear.

    Non-adhesive dressings are applied and a wool and crepe bandage applied.In this case the foot has been left free, with no splint, to allow the ankle and foot to be mobilised immediately. In calcaneal fractures managed with open approaches I splint the limb in plaster for the first 2 weeks to allow the soft tissues to settle and the wounds to heal before mobilisation of the foot and ankle are begun and then tend to use an aircast boot to protect the foot until full weight bearing is begun (usually about 3 months post-operatively).

    Post Operative

    Post-operatively the patient is advised to elevate the limb to control swelling in the foot. Patients are kept non-weight-bearing for the first 6 weeks post-operatively and then progress to full weight-bearing over the following six weeks. Ankle and foot movements are started immediately. Venous thrombosis-emboism prophylaxis is given for 6 weeks as per NICE guidelines.
    Patients are seen in clinic at 2 weeks for a wound review and removal of sutures and then at 6 weeks, 3 months and 6 months with xrays to assess clinical and radiological progress.

    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).
    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

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