Preoperative Patient Care A Intermediate Evaluation and Management 1 Obtain focused history and performs focused exam mechanism of injury check neurovascular status check soft tissue differential diagnosis and physical exam tests 2 Interprets basic imaging studies interpret radiographs (AP/Lat/Oblique and Harris/Broden views) interpret CT scan 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop: 2-3 Week Postoperative Visit wound check and remove sutures remove splint and place in short-leg cast boot non-weight bearing postop: ~ 4 week Postoperative Visit remove cast and place in CAM boot non-weight bearing begin range of motion exercises to ankle and foot postop: 10-12 week Postoperative Visit advance weight-bearing status in CAM boot advance rehabilitation B Advanced Evaluation and Management 1 Recognizes concomitant associated injuries 2 Appropriately orders and interprets advanced imaging studies CT Scan 3 Modifies and adjusts post-operative treatment plan as needed 4 Provides comprehensive assessment of complex fracture patterns on imaging studies 5 Recognizes indications for and provides non-operative treatment of an unstable fracture diabetes medical comorbidities non-compliance C Preoperative H & P 1 Obtain history and perform basic physical exam history age gender history of present illness [HPI] past medical history [PMHx] social history physical exam range of motion effusion neurovascular status 2 Screen medical studies to identify and contraindications for surgery 3 Orders basic imaging studies order radiographs (AP/Lat/Oblique and Harris/Broden views) order CT scan 4 Perform operative consent describe complications of surgery including 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 Operative Techniques E Preoperative Plan 1 Template fracture with radiographs 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 2 Execute surgical walkthrough describe the steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Calcaneus Plating System (Stryker Veriax Calcaneus System) 2 Room setup and equipment standard OR table with radiolucent end c-arm in from contralateral side end of bed at ~20° to get Harris heel view 3 Patient positioning 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 G Lateral Approach to Calcaneus 1 Mark out lateral malleolus and lateral border of Achilles exsanguinate limb and inflate tourniquet 2 Start incision 2-4 cm proximal to lateral malleolus on the posterior border of the fibula extend incision down posterior fibula and bend around lateral maleolus over the peroneal tubercle curve distally to a point 4 cm inferior and 2.5 cm anterior to lateral malleolus follow the course of the peroneal tendons 3 Mobilize skin flaps be careful to avoid sural nerve and short saphenous vein that run posterior to the lateral malleolus 4 Expose the peroneal tendons incise the deep fascia to uncover the peroneal tendons incise the inferior peroneal retinaculum over peroneus brevis must repair at end of case to prevent dislocation incise sheath of peroneus longus mobilize peroneal tendons and retract them anteriorly over the lateral malleolus H Deep dissection 1 Identify calcaneofibular ligament and incise locate the posterior talocalcaneal joint capsule and incise it transversly inverting the foot will expose the articular surface to expose lateral surface of calcaneus perform subperiosteal dissection inferiorly 2 Isolate peroneal tendons divide superficial and deep fascia if necessary and there is no infection may divide tendons by Z-plasty and repair at end of case 3 Perform subperiosteal dissection incise and elevate the periosteum below the tendons subperiostally elevate tissues (including tendons) superiorly and inferiorly off the lateral surface of the calcaneus 4 Use “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 I Bony Preparation 1 Identify the fracture lines delineate fracture lines with knife and clean out using freer, curettes, and rongeur 2 Identify the fracture fragments 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 check to see how remaining fragments fit together break apart fragments with curved osteotome and lever to regain calcaneus height identify if there is a central void of comminution due to bone loss J Reduction 1 Restore ant/med/post facet of subtalar joint remove fragments if needed and temporarily pin into place with multiple kwires use kwires to join pieces together check Bohlers angle and angle of Gissane with fluoro use kwires through bottom of calcaneus to pin constant fragment to remaining fragments 2 Place large shantz pin drill large Shantz pin into posteroinferior aspect of calcaneus perpendicular to bone to gain traction through fragment use bolt cutter to remove sharp end, T-handle to apply traction through pin and distract fragments 3 Reduce the periphery of the calcaneous build periphery of calcanues and later fill in central void with allograft chips, tamp in gently 4 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 K Fixation 1 Place lag screw use a 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 2 Check calcaneus plate sizing on Lat fluoro 3 Fill central void of the calcaneous use bone chips allograft, then place lat wall fragment back into place 4 Fix the plate to the calcaneous first place bicortical nonlocking screws into the anterior and posterior aspects of plate to compress plate down to bone check position on fluoro 5 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 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 6 Check with fluoro on AP/Lat/Harris views exchange screws that are too long medially to avoid tendon irritation (FHL) and damage L Wound Closure 1 Irrigation, hemostasis, and drain irrigate wounds thoroughly and deflate tourniquet cauterize any bleeders carefully, watching out for saphenous vein hemovac drain deep exiting superolateral from incision 2 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) 3 Dressing and immediate immobilization dress the incision(gauze, webril) followed by postmold splint with extra padding under heel for immobilization crutches or walker for ambulation Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders orders IV fluids prescribe DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care appropriately orders and interprets basic imaging studies check radiographs of the foot in post op 2 Appropriate medical management and medical consultation 3 Physical Therapy non weightbearing 4 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks R Complex Patient Management 1 Develops unique, complex post-operative management plans 2 Capable of evaluating and treating postoperative complications 3 Surgically treats complex complications
A Intermediate Evaluation and Management 1 Obtain focused history and performs focused exam mechanism of injury check neurovascular status check soft tissue differential diagnosis and physical exam tests 2 Interprets basic imaging studies interpret radiographs (AP/Lat/Oblique and Harris/Broden views) interpret CT scan 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop: 2-3 Week Postoperative Visit wound check and remove sutures remove splint and place in short-leg cast boot non-weight bearing postop: ~ 4 week Postoperative Visit remove cast and place in CAM boot non-weight bearing begin range of motion exercises to ankle and foot postop: 10-12 week Postoperative Visit advance weight-bearing status in CAM boot advance rehabilitation B Advanced Evaluation and Management 1 Recognizes concomitant associated injuries 2 Appropriately orders and interprets advanced imaging studies CT Scan 3 Modifies and adjusts post-operative treatment plan as needed 4 Provides comprehensive assessment of complex fracture patterns on imaging studies 5 Recognizes indications for and provides non-operative treatment of an unstable fracture diabetes medical comorbidities non-compliance C Preoperative H & P 1 Obtain history and perform basic physical exam history age gender history of present illness [HPI] past medical history [PMHx] social history physical exam range of motion effusion neurovascular status 2 Screen medical studies to identify and contraindications for surgery 3 Orders basic imaging studies order radiographs (AP/Lat/Oblique and Harris/Broden views) order CT scan 4 Perform operative consent describe complications of surgery including 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
E Preoperative Plan 1 Template fracture with radiographs 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 2 Execute surgical walkthrough describe the steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Calcaneus Plating System (Stryker Veriax Calcaneus System) 2 Room setup and equipment standard OR table with radiolucent end c-arm in from contralateral side end of bed at ~20° to get Harris heel view 3 Patient positioning 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 G Lateral Approach to Calcaneus 1 Mark out lateral malleolus and lateral border of Achilles exsanguinate limb and inflate tourniquet 2 Start incision 2-4 cm proximal to lateral malleolus on the posterior border of the fibula extend incision down posterior fibula and bend around lateral maleolus over the peroneal tubercle curve distally to a point 4 cm inferior and 2.5 cm anterior to lateral malleolus follow the course of the peroneal tendons 3 Mobilize skin flaps be careful to avoid sural nerve and short saphenous vein that run posterior to the lateral malleolus 4 Expose the peroneal tendons incise the deep fascia to uncover the peroneal tendons incise the inferior peroneal retinaculum over peroneus brevis must repair at end of case to prevent dislocation incise sheath of peroneus longus mobilize peroneal tendons and retract them anteriorly over the lateral malleolus H Deep dissection 1 Identify calcaneofibular ligament and incise locate the posterior talocalcaneal joint capsule and incise it transversly inverting the foot will expose the articular surface to expose lateral surface of calcaneus perform subperiosteal dissection inferiorly 2 Isolate peroneal tendons divide superficial and deep fascia if necessary and there is no infection may divide tendons by Z-plasty and repair at end of case 3 Perform subperiosteal dissection incise and elevate the periosteum below the tendons subperiostally elevate tissues (including tendons) superiorly and inferiorly off the lateral surface of the calcaneus 4 Use “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 I Bony Preparation 1 Identify the fracture lines delineate fracture lines with knife and clean out using freer, curettes, and rongeur 2 Identify the fracture fragments 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 check to see how remaining fragments fit together break apart fragments with curved osteotome and lever to regain calcaneus height identify if there is a central void of comminution due to bone loss J Reduction 1 Restore ant/med/post facet of subtalar joint remove fragments if needed and temporarily pin into place with multiple kwires use kwires to join pieces together check Bohlers angle and angle of Gissane with fluoro use kwires through bottom of calcaneus to pin constant fragment to remaining fragments 2 Place large shantz pin drill large Shantz pin into posteroinferior aspect of calcaneus perpendicular to bone to gain traction through fragment use bolt cutter to remove sharp end, T-handle to apply traction through pin and distract fragments 3 Reduce the periphery of the calcaneous build periphery of calcanues and later fill in central void with allograft chips, tamp in gently 4 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 K Fixation 1 Place lag screw use a 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 2 Check calcaneus plate sizing on Lat fluoro 3 Fill central void of the calcaneous use bone chips allograft, then place lat wall fragment back into place 4 Fix the plate to the calcaneous first place bicortical nonlocking screws into the anterior and posterior aspects of plate to compress plate down to bone check position on fluoro 5 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 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 6 Check with fluoro on AP/Lat/Harris views exchange screws that are too long medially to avoid tendon irritation (FHL) and damage L Wound Closure 1 Irrigation, hemostasis, and drain irrigate wounds thoroughly and deflate tourniquet cauterize any bleeders carefully, watching out for saphenous vein hemovac drain deep exiting superolateral from incision 2 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) 3 Dressing and immediate immobilization dress the incision(gauze, webril) followed by postmold splint with extra padding under heel for immobilization crutches or walker for ambulation
O Perioperative Inpatient Management 1 Write comprehensive admission orders orders IV fluids prescribe DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care appropriately orders and interprets basic imaging studies check radiographs of the foot in post op 2 Appropriate medical management and medical consultation 3 Physical Therapy non weightbearing 4 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks R Complex Patient Management 1 Develops unique, complex post-operative management plans 2 Capable of evaluating and treating postoperative complications 3 Surgically treats complex complications