35 Open Reduction Internal Fixation Using an Extensile Lateral Approach for a Joint Depression Fracture

35.Open Reduction Internal Fixation Using an Extensile Lateral Approach for a Joint Depression Fracture

Roy W. Sanders

Paul Tornetta III

Indications/Contraindications

The indications for open reduction and internal fixation (ORIF) of the calcaneus remain controversial. Results after surgery are superior to nonoperative management outcomes only if the posterior facet is anatomically reduced and if complications are avoided (1,2,3). The best indication for internal fixation of the calcaneus is an intra-articular fracture with displacement of the posterior facet in a young active patient with no medical problems. Middle-aged patients should be considered operative candidates based on their lifestyles and fracture patterns. The more active a patient is, the more likely that he/she would benefit from properly performed surgery. Even in less active patients, surgery may improve the functional result if the fracture displacement produces significant widening or shortening of the heel, because skeletal distortion increases the chances of a poor result when the fracture is treated nonoperatively.

Contraindications to surgery may be related to the patient's overall health, including mental status, the fracture pattern, and/or the surgeon's experience. Relative contraindications to internal fixation include neuropathy, insulin-dependent diabetes, peripheral vascular disease, venous stasis or congestion, lymphedema, immune compromise, and other disorders or behaviors, such as smoking, that might impede healing. Advanced age is a relative contraindication. Patient compliance is important in obtaining a good functional result after surgical intervention and must be considered preoperatively. Patients with a history of jumping from heights must be carefully scrutinized for signs of mental illness or depression. When appropriate, these patients should be evaluated by a mental health professional.

Despite improved surgical techniques and implants, a subset of calcaneal fractures with severe comminution of the posterior facet are resistant to anatomic reduction and internal

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fixation. In these injuries, primary fusion may be a good alternative to internal fixation. Less comminuted but complex injuries with multiple fractures through the posterior facet offer a relative contraindication for surgeons who do not have significant experience in the operative treatment of calcaneal fractures.

Open fractures present difficult management problems. A thorough irrigation and debridement of the traumatic wounds and the fracture constitute the first priority after resuscitation and trauma evaluation. If the wound is lateral and allows reduction of the posterior facet, then it is reduced and fixed with lag screws. This is performed only after re-prepping and redraping after the debridement. If the wound is medial, internal fixation is delayed until the soft-tissue environment has been addressed. Temporary, triangular, external fixation on the lateral side of the foot and ankle can be used to maintain the general alignment of the heel until definitive management is undertaken. The external fixation pins are placed in the tuberosity, the cuboid, and the talus. Definitive ORIF is performed 2 to 3 weeks after wound closure if the soft tissues are in good condition.

Preoperative Planning

Initial Survey

Physical examination of the patient with a calcaneus fracture must include a careful and complete survey of the axial as well as the appendicular skeleton. Spinal fractures are common in patients with calcaneal fractures because the mechanism of injury is often axial loading caused by a fall from a height. X-rays of the affected extremity and spine should be routine.

To rule out open fracture or compartment syndrome, the surgeon begins the physical examination of the foot and ankle with the evaluation of the soft tissues. Compartment syndrome of the foot is difficult to diagnose clinically. Calcaneal fractures are painful but usually respond to splinting, elevation, ice, and analgesics. Severe and unrelenting pain should be considered a compartment syndrome until proven otherwise. Significant swelling in the foot is common after calcaneal fracture, and the region may not feel tense even in the face of compartment syndrome. Sensation is rarely affected, and its absence does not rule out compartment syndrome. Pain on passive extension of the metatarsophalangeal joints is the best method of clinical examination but is not sensitive enough to rule out a compartment syndrome.

Direct, intracompartmental, pressure measurement is the most accurate method of diagnosis. Pressures should be taken in the central (interosseous) and medial compartments. Handheld devices and arterial line monitors are equally effective in measuring compartment pressures. We perform a fasciotomy if the compartment pressure is within 30 mm Hg of the diastolic pressure. If the pressure measurements are borderline and if significant clinical symptoms are absent, then the foot may be observed and pressures rechecked in 30- to 60-minute intervals. If a fasciotomy is required, the calcaneal fracture is not usually fixed at this time because the incisions necessary for the fasciotomy are not useful for reduction and fixation of the calcaneus.

The remainder of the physical examination of the foot and ankle is directed at diagnosing concomitant injuries. Palpation of the entire lower leg, ankle, and foot may help in identifying such injuries. Commonly associated regional injuries include ankle fractures (especially the lateral malleolus), ankle-ligament injury, peroneal tendon dislocation, mid foot fractures, talar fractures, and metatarsal fractures. Radiographic evaluation of symptomatic or suspicious areas is essential.

Specific Radiographs

The specific radiographs that are necessary to evaluate an injury to the hind foot include anteroposterior (AP), lateral, and mortise views of the ankle; AP, lateral, and oblique views of the foot; and an axial view of the calcaneus (Harris view). Contralateral axial and lateral views of the calcaneus and an oblique view of the contralateral foot may be useful in delineating the patient's normal anatomy. The ankle radiographs are necessary so the surgeon can

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rule out concomitant ankle or talar fractures as well as evaluate the calcaneus, subtalar joint, and calcaneocuboid joint. The lateral view of the calcaneus allows preliminary classification of the fracture and information about the integrity of the posterior facet (Fig. 35.1).

Even in comminuted and displaced fractures, a portion of the posterior facet is usually intact, and the relationship of the subtalar joint can be evaluated. The lateral radiograph may demonstrate a double density when part of the posterior foot is impacted or depressed. This image may be confused with an oblique view of the joint. However, the confusion can be clarified easily because in a true oblique view the posterior facet of the talus will also appear as a double density, and in a calcaneal fracture, it will appear as only one line. The calcaneocuboid joint and anterior calcaneus are best visualized on the foot films. The axial view demonstrates the position of the tuberosity, the status of the medial wall, and the location of the fracture(s) through the facet (Fig. 35.2).

Computed Tomography Scans

To gain a better understanding of the fracture morphology, the surgeon obtains bi-planar computed tomography (CT) scans with 2- or 3-mm cuts. The scan should include images in the plane of the foot as well as in a plane perpendicular to the posterior facet of the talus. The most important of these are the axial images of the hind foot perpendicular to the posterior facet of the talus. The image is described in reference to the talus because the posterior facet of the calcaneus is displaced. This view is obtained with the foot flat on the table, the knee flexed, and the gantry angled 30 degrees forward. The axial images are used to classify the fracture and to evaluate the fracture anatomy. The surgeon should make note of pertinent anatomic points such as the position and integrity of the tuberosity, the location and number of fractures in the posterior facet, displacement of the lateral wall, the location of medial-wall comminution or fracture lines, the size of the sustentacular fragment, fractures in the anterior calcaneus, the presence or absence of an anterolateral fragment, and the position of the peroneal tendons (dislocated or not) (Figs. 35.3 and 35.4).

The lateral view of the calcaneus demonstrates a joint-depression fracture with a portion of the posterior facet impacted into the cancellous bone of the tuberosity. The sagittal plane rotation of the displaced posterior facet is best seen on this view.

Figure 35.1. The lateral view of the calcaneus demonstrates a joint-depression fracture with a portion of the posterior facet impacted into the cancellous bone of the tuberosity. The sagittal plane rotation of the displaced posterior facet is best seen on this view.

The axial (Harris) view demonstrates the primary fracture line, medial comminution, the fractures into the facet, and the varus angulation of the tuberosity.

Figure 35.2. The axial (Harris) view demonstrates the primary fracture line, medial comminution, the fractures into the facet, and the varus angulation of the tuberosity.

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The CT images in the plane of the foot are used to evaluate the anterior calcaneus and sustentaculum tali. Fractures of the sustentacular fragment in the coronal plane may decrease the bone available for fixation of the facet. These fractures may not be seen in the other radiographs or axial CT scans but are visible on the CT images of the plane of the foot (Fig. 35.5).

 The 30-degree semicoronal CT image demonstrates the comminution and degree of depression of the posterior facet. The separation and step-off are easily seen, but the sagittal plane rotation of the fragments is not well visualized. The wedging effect of the tuberosity fragment separating the facet fragments and the lateral wall blowout is well visualized.

Figure 35.3. The 30-degree semicoronal CT image demonstrates the comminution and degree of depression of the posterior facet. The separation and step-off are easily seen, but the sagittal plane rotation of the fragments is not well visualized. The wedging effect of the tuberosity fragment separating the facet fragments and the lateral wall blowout is well visualized.

 A CT image farther anterior demonstrates a separate anterolateral fragment (open arrow).

Figure 35.4. A CT image farther anterior demonstrates a separate anterolateral fragment (open arrow).

Classification

The fracture is classified by the system of Essex Lopresti (4) by using the plain films and by that of Sanders (5) from the 30-degree, semicoronal, CT scan (Fig. 35.6). By initially classifying the injury into either a joint depression or tongue-type fracture, the surgeon can better plan the reduction tactic. The Sanders classification was devised based on the ease of reduction and fixation via the lateral approach and has been predictive of outcome (2,5). The greater the number of fractures in the facet and the more medial their location, the harder will be the reduction. In the Sanders classification, the fracture lines are designated A through C by their location from lateral to medial, respectively. In a type 2C fracture, the entire facet is displaced from the intact medial calcaneus.

Planning the Reduction and Fixation

Before undertaking the ORIF, the surgeon must thoroughly understand the anatomy of the fracture, not only as it relates to displacement but also as it relates to the tactic for surgical reduction. Two steps are critical in planning the reduction and fixation of a calcaneal fracture. First are references for reduction, which include the anteroinferior margin of the facet (the angle of Gissane), the posterior facet of the

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talus, the intact posterior facet of the calcaneus, the calcaneocuboid joint, the tuberosity, and the lateral wall. Second are the standard fixation points used, which include the sustentaculum tali, medial wall, tuberosity, and anterior calcaneus.

The CT scan in the plane of the foot is the best view to evaluate the sustentaculum region. On this CT image, a vertical fracture through the sustentaculum, which is not seen on any other projection, is visible (solid arrow). The displaced lateral portion of the posterior facet is seen to be impacted into the tuberosity adjacent to the sustentacular region. The separate anterolateral fragment is seen on this view as well (open arrow).

Figure 35.5. The CT scan in the plane of the foot is the best view to evaluate the sustentaculum region. On this CT image, a vertical fracture through the sustentaculum, which is not seen on any other projection, is visible (solid arrow). The displaced lateral portion of the posterior facet is seen to be impacted into the tuberosity adjacent to the sustentacular region. The separate anterolateral fragment is seen on this view as well (open arrow).

The CT classification of Sanders. The fracture is described by the number and location of fracture lines in the posterior facet. Each fracture is given a number and a letter corresponding to the number of fragments of the posterior facet and their location.

Figure 35.6. The CT classification of Sanders. The fracture is described by the number and location of fracture lines in the posterior facet. Each fracture is given a number and a letter corresponding to the number of fragments of the posterior facet and their location. For example, a 2B fracture has one fracture line in the B location (see Fig. 35.3), and a 3BC has two fracture lines, one in the B position and one in the C position.

The wrinkle test is done by bringing the foot from the plantarflexed position (A) into dorsiflexion and observing the wrinkles (B) that form on the lateral side of the ankle and foot.

Figure 35.7. The wrinkle test is done by bringing the foot from the plantarflexed position (A) into dorsiflexion and observing the wrinkles (B) that form on the lateral side of the ankle and foot.

Evaluation of the Soft Tissues

So that postoperation wound complications are avoided, the initial postinjury swelling must be resolved. This commonly takes 10 to 21 days to occur but dramatically improves the condition of the soft tissues. The lateral bulge caused by lateral wall displacement can be confused with swelling, so the pliability of the skin is a better characteristic than swelling to test the status of the soft tissues.

Blisters are a contraindication for surgery. If they are blood filled, then they should be allowed to resolve without intervention. Clear blisters are aspirated and then unroofed several days later. In either case, blisters are treated as burns once they are open. Sterile dressings with silver sulfadiazine (Silvadene) cream are used until epithelialization occurs.

If blisters are eliminated, the 鈥渨rinkle鈥� test is a good predictor of whether the soft tissue will tolerate surgery. It is performed by bringing the ankle from a plantar-flexed position to neutral. If the skin wrinkles, then it is ready for surgery (Fig. 35.7). Ecchymosis is common and is often distributed along the peroneal tendons. As long as blisters are absent, this is not a contraindication to surgery. The foot is kept in a bulky dressing of soft roll and elevated until the soft tissues will tolerate the surgery. The patient may be discharged home and the foot examined every 5 days until the swelling resolves.

Surgery

For proper treatment of all patients, high-quality plain radiographs (Figs. 35.8 and 35.9) as well as a CT scan (Fig. 35.10) must be obtained prior to surgery. Once soft-tissue swelling has decreased and skin wrinkling is seen, surgery can be performed. The patient is placed on the operating room table in the lateral decubitus position, and a beanbag or some other device is used to maintain torso stability. The legs are placed apart, in a scissor-like configuration such that the contralateral down limb is straight, and the operative limb is bent at the knee. The operative heel should lie at the corner of the table so that the surgeon can easily access the limb and the fracture. In addition, this positioning will allow the surgeon to use the c-arm without superimposition of the opposite leg. The nonoperative leg

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should have padding placed to protect the peroneal nerve as well as any bony prominences, and a pillow is placed between the legs (Fig. 35.11).

 Plain radiographs of a joint depression fracture. The depressed joint fragment (white arrow) is impacted below the stable medial fragment. This creates a double density. The impaction of the posterior tuberosity is noted by the dotted red line.

Figure 35.8. Plain radiographs of a joint depression fracture. The depressed joint fragment (white arrow) is impacted below the stable medial fragment. This creates a double density. The impaction of the posterior tuberosity is noted by the dotted red line.

Broden's view of intra-articular fracture. This is a perfect mortise view of the ankle. Primary fracture line is shown by black arrows, and the shifted superolateral fragment is indicated by red arrows.

Figure 35.9. Broden's view of intra-articular fracture. This is a perfect mortise view of the ankle. Primary fracture line is shown by black arrows, and the shifted superolateral fragment is indicated by red arrows.

CT scan of fracture. The superolateral fragment (*) is seen on both the semicoronal (A) and transverse (B) projections

Figure 35.10. CT scan of fracture. The superolateral fragment (*) is seen on both the semicoronal (A) and transverse (B) projections.

The lateral extensile incision is then marked (Fig. 35.12). A drawn line is initiated from 2 cm proximal to the tip of the lateral malleolus, at the lateral edge of the Achilles tendon, and is continued down toward the plantar surface of the heel. As the surgeon's pen approaches the heel pad, the line is curved to parallel the superior edge of the pad. The marking then follows the pad toward the insertion of the peroneus brevis tendon, but it should be angled up so that the surgeon can access the calcaneocuboid joint if needed.

The limb is exsanguinated and a tourniquet is used. The skin incision is made at the proximal part of the vertical limb and extended plantarly. The incision should become full thickness when the calcaneal tuberosity is reached, and the surgeon should avoid beveling the skin when turning the corner with the knife. As the knife parallels the plantar surface of the foot, pressure is again relaxed and a layered incision is developed distally.

A full thickness flap is then developed by raising the corner of the incision subperiosteally (Fig. 35.13). When the periosteal flap is partially developed, retractors may then be used to pull the periosteum upward (Fig. 35.14). Earlier use of retractors will tear the skin away from the periosteum, which could potentially cause late necrosis of the skin.

With continued dissection, the calcaneofibular ligament is encountered and resected from the calcaneus; this will expose the peroneal tendons and their inferior sheath at the level of the peroneal tubercle. The peroneal tendons must be carefully identified and retracted, or one or both tendons will be lacerated during the dissection (Figs. 35.15 to 35.17).

Once the flap is sufficiently developed, the peroneal tendons are slightly subluxed anteriorly, and a 1.6-mm Kirschner (K) wire is then inserted into the fibula to retract the peroneal tendons. A second K wire is placed in the talar neck to retract the midportion of the peroneal tendons and the skin flap, and a third K wire is placed in the cuboid, thereby retracting the distal aspect of the peroneal tendons and the full-thickness skin flap. The exposure of the entire lateral wall can be completed by placing a small retractor into the sinus tarsi over the anterolateral corner of the calcaneus (Fig. 35.18).

 Positioning of the patient.

Figure 35.11. Positioning of the patient.

 Lateral extensile incision (red line, landmarks), (black arrow, direction of distal end of incision used to access calcaneocuboid joint). Also, the skin has ample wrinkles, indicating that edema is no longer in the skin flap.

Figure 35.12. Lateral extensile incision (red line, landmarks), (black arrow, direction of distal end of incision used to access calcaneocuboid joint). Also, the skin has ample wrinkles, indicating that edema is no longer in the skin flap.

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The exposed corner of the calcaneal tuberosity is then predrilled and a short Schantz pin is screwed into place. Using the pin, the heel is manipulated and distracted into varus, which disimpacts the fracture and makes the edge of the fragment more visible (Fig. 35.19).

Subperiosteal development of lateral flap

Figure 35.13. Subperiosteal development of lateral flap.

. Retractor placed after full thickness flap is developed

Figure 35.14. Retractor placed after full thickness flap is developed.

Exposure of peroneal tendons (*, peroneal brevis tendon)

Figure 35.15. Exposure of peroneal tendons (*, peroneal brevis tendon).

Exposure of inferior peroneal-tendon sheath.

Figure 35.16. Exposure of inferior peroneal-tendon sheath.

 Resection of inferior peroneal-tendon sheath from lateral wall, which protects tendons and permits retraction

Figure 35.17. Resection of inferior peroneal-tendon sheath from lateral wall, which protects tendons and permits retraction.

No touch technique in which three 1.6-mm K wires are used for retraction. The lateral wall is fully exposed, and the depressed lateral-joint fragment is visualized

Figure 35.18. No touch technique in which three 1.6-mm K wires are used for retraction. The lateral wall is fully exposed, and the depressed lateral-joint fragment is visualized (*).

Schantz pin disimpaction of joint. The superolateral fragment is shifted farther away from the medial joint surface than it is in Figure 35.18, which indicates that it is loose.

Figure 35.19. Schantz pin disimpaction of joint. The superolateral fragment is shifted farther away from the medial joint surface than it is in Figure 35.18, which indicates that it is loose.

Separation of lateral wall (dotted line) from superolateral fragment.

Figure 35.20. Separation of lateral wall (dotted line) from superolateral fragment.

The lateral wall fragment is then carefully resected from the impacted joint fragment and placed in a container with saline (Fig. 35.20). The farthest anterior plantar edge of the depressed superolateral fragment is located and a small periosteal elevator is placed underneath it. Disimpaction of the fragment is performed gradually because sudden strong pressure may result in the fragment falling on the operating room floor (Fig. 35.21). Once lifted, it should be removed, cleaned of clot, and placed in the same container as the lateral wall.

Disimpaction of superolateral fragment. The surgeon's thumb is holding the fragment laterally to maintain control during manipulation

Figure 35.21. Disimpaction of superolateral fragment. The surgeon's thumb is holding the fragment laterally to maintain control during manipulation.

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Once the superolateral fragment has been removed, attention is turned to the medial sustentacular component, the posterior tuberosity, and the primary medial-fracture line (Fig. 35.22). A periosteal elevator is placed into the medial fracture line from the lateral wound, and the posterior tuberosity is disimpacted from the sustentaculum (Fig. 35.23).

With the superolateral fragment removed, the medial sustentacular (constant) fragment (*) and the posterior tuberosity are easily seen. The primary fracture line, through the medial wall of the calcaneus (elevator), is identified.

Figure 35.22. With the superolateral fragment removed, the medial sustentacular (constant) fragment (*) and the posterior tuberosity are easily seen. The primary fracture line, through the medial wall of the calcaneus (elevator), is identified.

The articular fragment is now evaluated. It is cleaned of clot and impacted cancellous bone (Fig. 35.24). The articular fragment should be repositioned such that height, rotation, and varus-valgus alignment are correct. This will not be possible if the fragment hits the edge of the posterior tuberosity; therefore, the posterior-inferior path for the fragment must be free of bone. This may require the surgeon to curette excess bone from the tuberosity, disimpact the tuberosity with excess varus force, or with a rongeur remove a small amount of bone that is blocking the reduction (Fig. 35.25).

The anterior process must be repositioned before the articular fragment is placed. The anterior process may be in as many as three pieces with the middle fragment pulled proximally by the interosseous ligament. A laminar spreader placed in the sinus tarsi is used to stretch the ligament thereby allowing the central piece to be more easily reduced. The surgeon should avoid ligament resection because it will destabilize the joint. In addition, a transverse fracture line may be present at the angle of Gissane. This will rotate the medial articular fragment beneath the medial-anterior tuberosity fragment. Before reduction

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of the lateral articular fragment, the medial articular fragment must be repositioned, or the superolateral fragment will be reduced to a fragment that itself is not reduced.

Schematic and clinical view of posterior tuberosity disimpaction (red arrow, direction of insertion of periosteal elevator)

Figure 35.23. Schematic and clinical view of posterior tuberosity disimpaction (red arrow, direction of insertion of periosteal elevator).

 The superolateral fragment is cleaned of clot to assure perfect interposition during reduction.

Figure 35.24. The superolateral fragment is cleaned of clot to assure perfect interposition during reduction.

Schematic showing reduction maneuvers. A. While articular fragment is repositioned in height, it is still in valgus because the posterior tuberosity is blocking reduction. B. After the tuberosity is pulled out of the way and excess bone is rongeured off, the superolateral fragment now fits in both height and alignment (not shown is the third component of reduction, which shows rotation).

Figure 35.25. Schematic showing reduction maneuvers. A. While articular fragment is repositioned in height, it is still in valgus because the posterior tuberosity is blocking reduction. B. After the tuberosity is pulled out of the way and excess bone is rongeured off, the superolateral fragment now fits in both height and alignment (not shown is the third component of reduction, which shows rotation).

Provisional reduction of the superolateral fragment through use of two K wires to prevent rotation. The fragment is anatomically aligned at the angle of Gissane.

Figure 35.26. Provisional reduction of the superolateral fragment through use of two K wires to prevent rotation. The fragment is anatomically aligned at the angle of Gissane.

Once the articular surface is reduced, it is provisionally held with two K wires to prevent rotation (Fig. 35.26). At this point, the anterior lateral 鈥渃orner鈥� of the articular fragment should align with the anterolateral 鈥渃orner鈥� of the medial sustentacular fragment. The anterolateral fragment should either fall in place or be manipulated back into position and held with K wires. When this reduction is anatomic, the angle of Gissane will be restored. At this point, verifying that the lateral column is anatomically reduced, the surgeon places the lateral wall back.

Once satisfied with the reduction, the surgeon should obtain intraoperative lateral, Broden's, and axial fluoroscopic views. The lateral should show a true lateral of the talus, thereby guaranteeing an accurate view of the calcaneus (Fig. 35.27). Next, with the fluoroscope in the same position, the leg is externally rotated 45 degrees and the foot is dorsiflexed. A mortise view of the ankle is then obtained; it shows the posterior facet in a Broden's view (Fig. 35.28). Finally, the leg is externally rotated 90 degrees, and the foot is maximally dorsiflexed. The fluoroscope is then angled such that the head is on the plantar aspect of the mid foot and a clear axial view of the calcaneus is obtained (Fig. 35.29).

Lateral x-ray. A. Position with C-arm. B. Lateral fluoroscopic view. Anatomic reduction of calcaneal cuboid joint (red arrows), restoration of the angle of Gissane (lower white arrow), and restoration of Bohler's angle (higher white arrow).

Figure 35.27. Lateral x-ray. A. Position with C-arm. B. Lateral fluoroscopic view. Anatomic reduction of calcaneal cuboid joint (red arrows), restoration of the angle of Gissane (lower white arrow), and restoration of Bohler's angle (higher white arrow).

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The articular fragments should be repositioned until an anatomic reduction of the joint is accomplished. Fixation is then obtained using a 3.5-mm cortical screw placed in a lag mode. The screw should be directed from the lateral cortex and aimed slightly plantar to avoid violation of the intra-articular surface; it should extend distally toward the sustentaculum (Fig. 35.30). Once the screw is placed, the joint should be reassessed both visually and fluoroscopically.

Broden's view. A. Positioning with the limb externally rotated 45 degrees and dorsiflexed. B. Mortise view of the ankle will provide best view, but the joint is still gapped and not anatomically reduced (white arrow).

Figure 35.28. Broden's view. A. Positioning with the limb externally rotated 45 degrees and dorsiflexed. B. Mortise view of the ankle will provide best view, but the joint is still gapped and not anatomically reduced (white arrow).

Axial view showing repositioning of posterior tuberosity through use of axial K wire to maintain position. The tuberosity is not yet completely reduced out of varus.

Figure 35.29. Axial view showing repositioning of posterior tuberosity through use of axial K wire to maintain position. The tuberosity is not yet completely reduced out of varus.

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The calcaneal body is then definitively addressed. The anterolateral fragment and the posterior tuberosity are realigned to insure that the body is anatomically reduced. The small lateral-wall fragment is elevated so the surgeon can evaluate the cancellous defect below the joint. If a large cavity is present, the surgeon may elect to fill the void with either bone graft or a graft substitute. The lateral wall remnant is then repositioned, and a low-profile, lateral, neutralization plate is selected. One of the authors (RS) has developed a specific plate for this and uses it exclusively (Fig. 35.31). Bending of the plate is not recommended because this will throw the calcaneal tuberosity into varus.

Definitive fixation of articular surface. A. Lag screw (3.5 mm) is placed with antirotation K wires in place. B. X-ray verifies anatomic joint reduction. Gap is closed and the articular surface is aligned perfectly (white arrow).

Figure 35.30. Definitive fixation of articular surface. A. Lag screw (3.5 mm) is placed with antirotation K wires in place. B. X-ray verifies anatomic joint reduction. Gap is closed and the articular surface is aligned perfectly (white arrow).

Once plate position is acceptable, as determined by the lateral fluoroscopic view, cancellous fully threaded 4.0-mm screws are used to secure the three main components of the calcaneus: the anterior process, the posterior tuberosity, and the joint. The final reduction is verified fluoroscopically, and all K wires are removed (Fig. 35.32).

A. Low-profile, calcaneal, perimeter plate (ACE-DePuy, Warsaw, IN). B. Positioning of plate on lateral calcaneus and verification of size through use of fluoroscopy. In this case, a larger plate should be selected.

Figure 35.31. A. Low-profile, calcaneal, perimeter plate (ACE-DePuy, Warsaw, IN). B. Positioning of plate on lateral calcaneus and verification of size through use of fluoroscopy. In this case, a larger plate should be selected.

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Before closing the flap, the peroneal tendons should be evaluated to make sure they were not dislocated from the injury. A Freer elevator is placed into the peroneal tendon sheath at the distal inferior portion of the wound. It should advance within the sheath easily. While watching the skin, the surgeon pushes the elevator forward in an attempt to slip it over the malleolar tip. If he/she is successful, the sheath has been torn off the fibula (Fig. 35.33), and a repair must be performed. To expose the tendon sheath, a small incision (< 3 cm) is made in the skin over the posterior edge of the distal tip of the fibula. Using one or two suture anchors, the sheath is secured to the bone and the repair is tested. Once completed, the tendons will no longer dislocate over the edge of the fibula.

 Plate in position with final x-rays showing anatomic reduction of the fracture.

Figure 35.32. Plate in position with final x-rays showing anatomic reduction of the fracture.

A deep drain is placed to exit at the proximal tip of the vertical limb of the incision, and the wound is closed in a layered fashion. Deep figure-of-eight, individual, no. 0, absorbable sutures are placed in the corner of the wound. The surgeon works out to the end of each limb of the incision. The sutures are not tied but rather clamped until all deep sutures have been placed. Then, starting at the proximal and distal ends and working toward the corner of the incision, the surgeon hand ties the sutures sequentially; this technique will pull the flap and thus take tension off the corner of the wound, which is the most susceptible to wound necrosis. The skin is closed with no. 3 nylon suture using the modified Allg枚wer-Donati technique: The surgeon starts again at the ends and progresses toward the apex (Fig. 35.34). Sterile dressings are applied and the tourniquet is deflated. A bulky cotton dressing and Weber splint are then placed.

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The patient is maintained overnight in the hospital for pain control. Plain radiographs (Fig. 35.35) and CT scans (Fig. 35.36) are obtained the next day, and the drain is removed. The patient is then placed in a short-leg nonweight-bearing cast and discharged home. The patient is seen in the office for wound checks and cast exchanges. The sutures are removed only if the incision is fully sealed, usually between 4 and 6 weeks.

Evaluation of the peroneal tendon sheath. A. The insertion of an elevator into the sheath. B. An attempt is made to sweep the elevator over the fibula (arrow). This was not possible in this case.

Figure 35.33. Evaluation of the peroneal tendon sheath. A. The insertion of an elevator into the sheath. B. An attempt is made to sweep the elevator over the fibula (arrow). This was not possible in this case.

At 3 weeks, the patient is placed into an elastic stocking and fracture boot that is locked in neutral flexion. Early subtalar joint range-of-motion exercises out of the boot are initiated at this time; however, weight bearing is not permitted until 12 postoperative weeks have passed. If ceramic cement had been used to fill the void, weight bearing may be initiated earlier, typically at 6 weeks, but only if the wound has completely healed. In addition, we prefer that the patient sleep in the boot until weight bearing is initiated so that an equinus contracture is prevented. Once weight bearing is initiated, the patient is gradually transitioned into regular shoes as tolerated. Physical therapy, specifically for gait training and achieving balance, is also begun at this point. The patient is able to return to normal activity at 6 postoperative months.

 Wound closure. A. Figure-of-eight, interrupted, no. 0 Vicryl (Ethicon, Rutherford, NJ) are placed and tied from edges to corner (red arrows). B. Wound closure via an Allg枚wer-Denoti stitch with no. 3 nylon. The knots are placed on the outside.

Figure 35.34. Wound closure. A. Figure-of-eight, interrupted, no. 0 Vicryl (Ethicon, Rutherford, NJ) are placed and tied from edges to corner (red arrows). B. Wound closure via an Allg枚wer-Denoti stitch with no. 3 nylon. The knots are placed on the outside.

Final x-rays. A. Lateral view. B. Broden's view. C. Axial view

Figure 35.35. Final x-rays. A. Lateral view. B. Broden's view. C. Axial view.

 Postoperative CT scans. A. Coronal cuts. B. Transverse cuts. C. Sagittal reconstructions showing body reposition. Calcium phosphate cement was used as void filler (*).

Figure 35.36. Postoperative CT scans. A. Coronal cuts. B. Transverse cuts. C. Sagittal reconstructions showing body reposition. Calcium phosphate cement was used as void filler (*).


Recommended Readings

1. Buckley RE, Meek RN. Comparison of open versus closed reduction of intraarticular calcaneal fractures: a matched cohort in workmen. J Orthop Trauma 1992;6(1):216.

2. Sanders R, Fortin P, DiPasquale T, et al. Operative treatment in 120 displaced intraarticular calcaneal fractures: results using a prognostic computed tomography scan classification. Clin Orthop 1993;290:87.

3. Tornetta P III. Open reduction and internal fixation of the calcaneus using minifragment plates. J Orthop Trauma 1996;10(l):63鈥�67.

4. Essex Lopresti P. The mechanism, reduction technique and results in fractures of the os calcis. Br J Surg 1952;39:395.

5. Sanders R. Current concepts review: displaced intra-articular fractures of the calcaneus. J Bone Joint Surg 2000;82:225鈥�250.