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Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and Locking Screws

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

 

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