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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
Approaches
  • 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
Closure
  • 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
Complications
  • 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
 

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