Calcaneous Fracture ORIF 28415

Calcaneus fracture CT scan image

Calcaneous superior view

Calcaneous Anterior View

Bohler's angle calcareous xray

Gissane's Angle

Calcaneous Primary Fracture Line Image

 

 

synonyms:calcaneous fracture ORIF, calcaneous fracture fixation, calcaneal fracture open treatment

Calcaneous Fracture ORIF CPT

Calcaneous Fracture ORIF Indications

  • Calcaneous fractures with >3mm of articular displacement in young, active patients.
  • Bross widening of the heel with lateral dislocation of the tuberosity.
  • Flattening of the talar axis.
  • Threatened soft tissue compromise.
  • Females, patients not involved with workers compensation, physiologic age <50y/o, patients with higher initial Bohler angle, patients with occupations not involving stenous labor, simple intra-articular fracture patterns.(Bajammal S, JOT 2005;19:360)

Calcaneous Fracture ORIF Contraindications

  • Minimally displaced fx: Bohler's angle >0°, posterior facet step off <2mm, entire facet depressed as unit forming a secondary congruence with the talus.
  • Extensive soft tissue injuryprecluding surgery within the first 6 weeks.
  • Extensive smoking history (>1ppd)
  • Insulin dependent diabetics
  • Peripheral vascular disease
  • Advance osteoporosis
  • Advance rheumatoid arthritis
  • Severely comminuted fractures precluding ORIF: consider primar subtalar fusion.
  • Patients who will not follow post-operative instructions: elevation, NWB.
  • Young male involved in strenous labor
  • Patients involved in workers compensation (Bajammal S, JOT 2005;19:360)

Calcaneous Fracture ORIF Alternatives

  • Subtalar fusion
  • CRPP (consider for tonge-type fractures)
  • Non-operative treatment
  • Ilizarov (Emara KM, CORR 2005;439:215).

Calcaneous Fracture ORIF Pre-op Planning / Special Considerations

  • Wait for fracture blisters and edema to resolve before surgery; usually delay surgery 7-14 days.
  • Open fractures generally treated with I&D within 8hours with fracture fragment repositioning to alleviated skin tension with delayed fixation when soft tissues permit.
  • Consider bone graft sites depending on fracture configuration: iliac crest, proximal tibia, allograft, substitutes.
  • Calcaneous ORIF video available with Campbells 11th edition. (excellent video)
  • Plates: Acumed calcaneal plating system, Stryker VariAx Foot locked plating system,
  • Sinus tarsi approach  has significantly fewer deep infections/wound complications when compared with the extensile lateral approach.   (Song JH, Foot Ankle Int. 2019 Feb;40(2):167-177)

Calcaneous Fracture ORIF Technique

  • Pre-operative antibiotics, +/- regional block
  • General endotracheal anesthesia
  • Supine position on radiolucent table with heels jost off the end of the table. All bony prominences well padded.
  • Prep and drape in standard sterile fashion.
  • Oblique medial incision posterior to the NV bundle.
  • Lateral incision just anterior to the tip of the of the lateral malleolus, extending 5-6cm towards the heel, parallel to the sole of the foot. Risks: Sural nerve.
  • Expose fracture both medially and laterally. Remove all debris.
  • Place 2mm K-wire into posterior-inferior tuberosity, tension with a Kirshner bow and use for traction / ligomentotaxis reduction.
  • Reduction with temporary k-wire fixation procedes as follows: 1-anterior process; 2-Medial wall and medial posterior facet; 3-tuberosity; 4-posterior facet.
  • Ensure subchondral screws across posterior facet are proper length.  Long screws will be in FHL groove and irritate FHL tendon.
  • Reduce medial wall with and varify with fluro.
  • Fixation provided with low-profile plate with a minimum of: 2 screws in the anterior process, 2 in the subchonrdal posterior facet and 2 in the posterior tuberosity.
  • Consider medial wall fixation with 2.7mm plate or axially directed screws.
  • Consider augmentation with calcium phosphate cement.
  • Fixation must be strong enough to allow early motion.
  • Repair ankle ligaments if concomittant injury has occured. Usually with anchors.
  • Repair peroneal tendon sheath if concomittant injury has occured.
  • Irrigate.
  • Close in layers.

Calcaneous Fracture ORIF Complications

  • Infection
  • Wound helaing problems
  • Pain/swelling
  • Malunion-best treated with lateral wall exostectomy, peroneal tenolysis, +/- subtalar arthrodesis, +/- calcaneal osteotomy depending on type (Clare MP, JBJS 2005;87A:963-73). (Clare MP, Lee WE 3rd, Sanders RW. Intermediate to long-term results of a treatment protocol for calcaneal fracture malunions. J Bone Joint Surg Am. 2005 May;87(5):963-73). (Carr JB, Hansen ST, Benirschke SK. Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle. 1988 Oct;9(2):81-6
  • Nonunion
  • Subtalar arthritis
  • Sural nervepalsy (from surgical exposure)
  • Tibial nerve palsy (generally from initial injury)
  • Tendon entrapement / rupture (FHL)
  • Functional limitations
  • CRPS
  • Calcaneocuboid arthritis
  • Heel pad pain
  • Infection, Wound helaing problems, Pain/swelling, Malunion, Nonunion, Subtalar arthritis, Sural nerve palsy, Tibial nerve palsy, Tendon entrapement / rupture (FHL), functional limitations.

Calcaneous Fracture ORIF Follow-up care

  • Bulky jones dressing with posterior splint post-operative. Must keep foot elevated for first 36-72 hours to decrease incidence of wound healing problems.
  • 7-10 day f/u:calcaneous xrays, SLC, NWB. Consider cam-walker with gentle ROM exercises.
  • 4 wk follow-up: calcaneous xrays, compression stocking, cam-walker boot, gentle ankle/subtalar ROM exercises, NWB. Sub-talar motion = figure-of-eight motion, drawing alphabet with the great toe.
  • 3 months f/u: calcaneous xrays, 25% WB, progress to full WB over 1-2 weeks. Start PT for ROM, gait training.
  • 6 months f/u: calcaneous xrays, evaluate function outcome, ROM.
  • 1 year f/u: calcaneous xrays, evaluate function outcome, ROM.

Calcaneous Fracture ORIF Outcomes

  • Long terms patients often are unable to run, and have difficulty walking on uneven surfaces. Generally able to walk on flat surfaces, golf, swim, bike and do ADL's without difficulty.
  • Poor outcomes associated with smoking, IDDM, multiple medical comorbidities, non-compliance, workers compensation.
  • Heavy laborers / construction workers generally require job retraining.
  • Mean AOFAS score = 65.4 at a mean of 12.8years of follow-up. (Potter MQ, JBJS 2009;91A:1854).

Calcaneous Fracture ORIF Review References

  • Sangeorzan BJ, in Masters Techniques in Orthopaedic Surgery: The Foot and Ankle, 2002.
  • Benirschke SK, AAOS OKO
  • Rockwood and Green's Fractures in Adults 6th ed, 2006
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