Updated: 10/4/2016

[Blocked from Release] Calcaneus Fracture ORIF

Review Topic
Pearls & Pitfalls
Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I
  • Preparation
    • standard OR table with radiolucent end
    • C-arm from contralateral end of bed at ~20° to get Harris heel view with foot dorsiflexed
  • Positioning
    • lateral decubitus on beanbag with feet at end of bed
      • operative foot elevated under stack of blankets to make flat working surface
  • Approach
    • lateral approach to calcaneus with extensile L-shaped incision
      • vertical limb between lateral malleolus and Achilles
      • 90° turn with horizontal limb 3cm above plantar surface of foot
  • Bony Preparation and Reduction
    • clean out fracture lines and remove lateral wall
    • identify constant anteromedial fragment and build off of it with kwires
    • large Schantz pin into posteroinferior calcaenus for traction
  • Fixation
    • lag screws 3.5mm to join lateral to medial fragments
    • check plate size, fill central void with allograft, and replace lateral wall
  • Postoperative
    • 2 wks non-weight bearing in postmold splint
    • 10-12 wks non-weight bearing in CAM boot, range of motion exercises and progression of weight bearing
Planning & Preparation
  • Template Fracture
    • identify fracture pattern based on xrays (AP/Lat/Oblique and Harris/Broden views) and CT scan
      • analyze direction and number of fracture lines (Sanders classification)
      • evaluate joint depression, articular comminution, Bohlers angle, and angle of Gissane
      • if severe articular comminution may need to concurrently fuse subtalar joint
      • if tongue-type with mild displacement and shortening can perform closed reduction with percutaneous pinning
    • goal is to restore calcaneus height, width, alignment, and articular surface
  • Extremity Exam
    • need to check wounds for evidence of open fracture, assess lumbar spine xrays (10% association with L-spine fractures)
    • document soft tissue status, associated injuries, distal neurovascular status
    • check for signs of compartment syndrome
      • identify comorbidities (diabetes) and social factors (smoking) that correlate with complications and poor outcomes
  • OR Setup and C-arm 
    • standard OR table with radiolucent end
    • c-arm in from contralateral side end of bed at ~20° to get Harris heel view
Equipment & Positioning
  • Equipment
    • Calcaneus Plating System (Stryker Veriax Calcaneus System)
    • c-arm fluoroscopy
    • OR table with radiolucent end
  • Position
    • patient lateral decubitus on beanbag with feet at end of bed
    • place sheets between ipsilateral and contralateral extremities to make elevated flat working surface ~1’ in height
      • make sure body and legs are taped down (need flat surface to work on)
    • can alternatively place patient supine with table tilted away from surgeon
    • thigh tourniquet placed high on thigh with webril underneath
  • Lateral Approach to Calcaneus 
    • mark out lateral malleolus and lateral border of Achilles
    • extensile lateral L-shaped incision:
      • vertical limb of incision between lateral malleolus and Achilles 2-4cm proximal to lateral malleolus
      • then 90° turn with horizontal limb 3cm above plantar surface of foot
Surgical Technique
  • Approach 
    • place dry lap over marked incision
      • exsanguinate limb and inflate tourniquet
    • 15 blade through skin then tenotomy scissors to spread subcutaneous tissue in vertical direction with minimal soft tissue stripping
    • knife down to bone on calcaneus for full-thickness flaps
      • not at distal or proximal 2-3cm of incision due to peroneals and posterior tibial tendon
    • elevate periosteum sharply off calcaneus following contour of bone
      • need to follow bone closely anteriorly to not get into peroneals distally
      • be careful to avoid sural nerve and short saphenous vein posterior to lateral malleolus
      • inverting the foot will help expose the subtalar articular surface
    • “no touch” technique avoiding skin using three .062 kwires into ant/med/post aspect of talus
      • bend kwires with driver into two 90° angles as fixed internal retractors for subcutaneous and skin retraction
  • Bony Preparation
    • delineate fracture lines with knife and clean out using freer, curettes, and rongeur
    • identify lateral wall that is often broken off, remove piece, clean and mark orientation for later use, and place in saline on back table
    • next find constant anteromedial fragment and build off of it, checking to see how remaining fragments fit together
      • break apart fragments with curved osteotome and lever to regain calcaneus height
      • there is a central void of comminution due to bone loss
  • Reduction
    • remove fragments if needed and temporarily pin into place with multiple kwires
    • need to restore ant/med/post facet of subtalar joint
      • use kwires to join pieces together
      • check with fluoro Bohlers angle and angle of Gissane
    • kwires through bottom of calcaneus to pin constant fragment to remaining fragments
    • drill large Shantz pin into posteroinferior aspect of calcaneus perpendicular to bone to gain traction through fragment
      • bolt cutter to remove sharp end, T-handle to apply traction through pin and distract fragments
      • build periphery of calcanues and later fill in central void with allograft chips, tamp in gently
    • check AP/Lat/Harris fluoro to check calcaneus reduction in terms of height, width, alignment, and articular surface
      • use blue handle of lap around forefoot to pull foot into dorsiflexion for heel view
  • Fixation
    • place 3.5mm lag screw to join largest pieces lateral to medial (2.7mm drill, 3.5mm screws)
      • be careful of iatrogenic injury to FHL from long screws
    • check calcaneus plate sizing on Lat fluoro
    • fill in central void with bone chips allograft, then place lat wall fragment back into place
    • place bicortical nonlocking screws first in anterior and posterior aspects of plate to compress plate down to bone
      • check position on fluoro
    • place locking screws around periphery of plate
      • check on heel and Lat xrays
    • if performing simultaneous fusion of subtalar joint, place threaded guidepins for 8.0mm cannulated screws x2 through posterior facet of subtalar joint
      • use heel view 2cm apart for placement
        • check on fluoro Lat for placement into talar body
      • measure, drill calcaneus cortex, just into talar body, then place screw on power followed by hand
      • can use fully threaded (if significant comminution of subtalar joint) or partially threaded screws (for compression)
  • Confirm Hardware Position 
    • check with fluoro on AP/Lat/Harris views
    • exchange screws that are too long medially to avoid tendon irritation (FHL) and damage
  • Irrigation & Hemostasis
    • irrigate wounds thoroughly and deflate tourniquet
    • cauterize any bleeders carefully, watching out for saphenous vein
    • hemovac drain deep exiting superolateral from incision
  • Closure
    • subcutaneous closure with 2-0 vicryl
    • skin closure with 3-0 nylon horizontal mattress or Allgower-Donati stitch to reduce skin tension (diabetics, smokers)
  • Dressing and Splint
    • incision dressing (gauze, webril) followed by postmold splint with extra padding under heel for immobilization
    • crutches or walker for ambulation
Postoperative Care
  • 2 Weeks
    • wound check and remove sutures
    • remove splint and place in short-leg cast boot non-weight bearing
  • 4 Weeks
    • remove cast and place in CAM boot non-weight bearing
    • begin range of motion exercises to ankle and foot
  • 10-12 Weeks
    • advance weight-bearing status in CAM boot
    • advance rehabilitation
  • Document Complications
    • wound breakdown (10-25%, worse in diabetics, smokers, open fractures)
    • superficial and deep infections
    • malunion
    • nonunion
    • iatrogenic injury to peroneal tendons, sural nerve, saphenous vein
    • post-traumatic subtalar arthritis
    • lateral impingement with peroneal irritation
    • iatrogenic injury to FHL from lateral to medial screws
    • compartment syndrome

Please rate topic.

Average 5.0 of 1 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Topic COMMENTS (0)
Private Note