Reuben Notes

Fixation Methods

 

ORIF Essix-Lopresti

  1. <50 years
    • open if >50 then don’t ORIF due to healing potential
  2. correlated poor result with poor reduction – realized need for ORIF to properly reduce the posterior facet
  3. advocated early ROM
    • slipper cast
    • related to successful outcome
  4. Gissane spike – steinman pin – levers posterior facet back up against talus then applies cast to hold in place
    • if tongue fracture – pin percutaneously, closed procedure
      • posteriorly into tongue then lever up the fx fragments
    • if joint depression fracture – did through open lateral incision but same reduction technique
      • could visualize placing spike into posterior facet
    • still commonly used

 

ORIF – McReynolds

  1. medial approach to fixate calcaneus
  2. importance of sustentacular fragment (McReynold's Fragment)
    • 1st to realize importance of sustentaculum fragment
    • once compressive force from injury is released the sustentaculum and talus recoils because of deltoid ligaments and interosseous attachments  of the sustentaculum tali to talusà keep calcaneus in position
    • sustentacular fragment remains anatomic and is cornerstone for repair
    • put the rest of the pieces back based on where the sustentacular fragment is located
  3. negatives
    • a portion of the facet may stay with sustentaculum while the rest in shoved down into the main body of the calcaneus – step off fracture
    • more invasive approach
    • must watch for medial neurovascular structures and tendons
    • must go through medial wall of calcaneus
    • not as commonly used
    • remember to always build the calcaneus around the fx

 

ORIF – Palmer

  1. lateral approach
  2. raise posterior facet back up to anatomic position
  3. bone graft to buttress posterior facet after repositioning facet
  4. most commonly used today

 

Surgical Considerations

  1. Edema
    • need to do within hours (1st 8-12 hrs) of fracture (before there is gross edema) or wait (5-10 days) until edema has resolved
    • edema will cause dehiscence or difficulty in closure and causes tension on soft tissue
    • lateral incisions often dehisce anyway
    • if edema is already present it must be brought down before fracture is repaired
    • elevation
    • ice: won’t bring the current edema down, but future edema is managed
    • compression
      • compression pump to actively pump edema out of foot
  2. Fracture blister
    • can operate right through fracture blister
    • result of gross edema
  3. Antibiotic prophylaxis
    • hematoma and lots of dead space from compaction
    • usually long procedure – 2 hours
    • putting in lots of hardware
    • can have high incidence of infection so must prophylax
    • 1g ancef pre op- and 1g q8h for 24 hours post-op
    • usually kept for 2-3 days in the hospital
      • hemostasis, edema control, and antibiotic prophylaxis
  4. Incision planning
    • must plan incision around additional wounds or fractures
    • lateral skin is tenuous more likely to dehisce
  5. Bone graft use
    • if there isn’t sufficient bone stock for fixation a bone graft may be needed to hold the  posterior facet in place
    • defects can fill in quickly on their own due to the vascularity of the calcaneus
    • depends on size of defect; do you need additional support

 

Surgical Technique

  1. General/spinal anesthesia – paralysis of lower extremity for easier reduction, long case
  2. Thigh tourniquet
  3. Usually lateral incision – lateral extensile incision (“L” shaped incision)
    • L incision – l incision beginning just posterior to lateral mallelolus extending to base of 4th and5th met base area
    • L incision creates flap for greater exposure (move as one big flap)
    • incision parallels peroneal tendons and sural nerve, keep incision posterior and inferior to peroneal tendons and sural nerve to keep these structures within the flap
    • make incision all the way to bone (no layering) à decreases incidence of dehiscence, the more layers there are the greater the incidence of dehiscence
    • lateral wall blow out gives natural window into calcaneus
    • atraumatic technique
  4. Use no-touch retraction – suture flap open or use k-wires, don’t keep pulling on flap
  5. Reflect pieces of lateral wall that blew out to get to posterior facet
  6. Use freer elevator to lever the posterior facet back to its position
  7. Use bone curette and remove all of hematoma, can also use pulsed lavage
  8. Reduce other fractures – tuberosity (get out of varus position using spike))
    • tuberosity – may need k-wire, recreate fracture, distract and reduce fracture
  9. When fixating use fluoroscopy – if fixation it too far it may go into tendons or neurovascular bundle
    • temporarily fixate with K-wires through posterior facet into sustentaculum tali
  10. Place joint into ROM to look for incongruity
  11. Permanently fixate – calcaneal reduction plate (Sander’s Plate), several different plates can be used, just reduce the fracture – 1st screw is usually the one through the posterior facet
    • fixate into sustentacular fragment – from lateral to medial, holds articular surface in position with the STJ,
    • if there is not enough bone stock, a bone graft of appropriate size can be used to buttress the posterior facet in position
    • can use screws, k-wires, or bone staples to fixate
  12. Close in 2 layers – periosteum (if present); the skin flap
  13. Always use drain – closed suction drain
  14. Light compressive dressing
  15. Keep overnight – draining, hemostasis, neurovascular status, prophylactic antibiotic
  16. Post-Op Care
    • early ROM – one consensus with in the literature
      • begin when wound is beginning to heal to decrease chance of dehiscence – 10 days
      • use removable cast boot to start early ROM
    • delayed weight bearing
      • 3 months average depending on extent of fracture, comminution, and loss of bone stock
      • 8-12 weeks, usually 12 weeks NWB
    • follow radiographically
    • WB for 1 month (4 weeks) in cast – CAM walker – when there are signs of osseous healing
    • WB in shoe
    • usually 3-4 months to get in shoe but still have disability and pain
    • may take 1-2 years for full rehabilitation

 

Complications

  1. heal
  2. infection
    • flush periodically during surgery, remove hematoma, antibiotic prophylaxis, good atraumatic technique, need to consider especially if patient is immunocompromised
  3. Joint stiffness
    • biggest complication, should be expected with calcaneal fracture, nature of the fracture
  4. DJD
    • Intra-articular fracture – will occur, may eventually need STJ fusion, if calcaneus has been repaired it will be easier to later fuse
    • importance of congruity and early ROM
  5. soft tissue impingement
    • peroneal tendons and sural nerve from lateral wall blow-out and widening of calcaneus
      • peroneal tendon synovitis and sural nerve entrapment
  6. mal-position
    • repair technique, reduce varus position of tuberosity
    • also be aware of height and width
    • a fluoroscopy a must
  7. non-union
    • rare due to vascularity of calcaneus (he has never seen this)
  8. heel pad damage
    • usually due to disruption of fibrous septae from impact from fall
  9. RSD
    • depends on extent of trauma
  10. compensatory injury
    • pain and stiffness will lead to altered gait which may cause injury elsewhere
  11. compartment syndrome
    • common