Preface: Contemporary Management of Displaced Intra-Articular Calcaneal Fractures

Transcription

1 Current Perspectives on Management of Calcaneal Fractures Foreword Thomas J. Chang xiii Preface: Contemporary Management of Displaced Intra-Articular Calcaneal Fractures xv Clinical Management of Acute, Closed Displaced Intra-Articular Calcaneal Fractures 163 Peter J. Hordyk, Brent A. Fuerbringer, and Performing a thorough clinical evaluation following an acute displaced intraarticular calcaneal fracture is paramount for optimal surgical timing and long-term outcome. Initial survey must entail a comprehensive evaluation to rule out concurrent injuries. Focused lower extremity examination must involve a complete neurovascular and soft tissue evaluation to identify such conditions as compartment syndrome or compromised integument, which necessitate urgent intervention. Establishing baseline radiographs and advanced imaging is vital for surgical planning. Once deemed stable, protocol-driven treatment is best to ensure proper control of pain and edema and adequate management of economic and patient safety concerns. Surgical Management of Displaced Intra-Articular Calcaneal Fractures: What Matters Most? 173 George T. Liu, Michael D. Vanpelt, Trapper Lalli, Katherine M. Raspovic, and Dane K. Wukich Displaced intra-articular calcaneal fractures are severe, complex injuries that can cause significant long-term functional impairment. Despite the controversies of whether these fractures should be treated operatively or nonoperatively, functional improvement can be seen with confounding variables that can be controlled by the surgeon. This article reviews prognostic factors that are associated with good functional outcomes following operatively treated displaced intra-articular calcaneal fractures. Intra-Articular Calcaneal Fractures: A Literature Review of Atraumatic Incisional Considerations 185 Adam Landsman, Garrett Melick, and Anusha Pundu When calcaneal fractures occur, the treating physician is faced with many decisions that are required to bring about a good clinical outcome. From a surgical perspective, decisions must be made regarding whether or not fixation is necessary, and if so, what will be used. Implicit in that thought process is planning of the surgical approach. This article shows that there are numerous considerations, including the level of edema, condition of the soft tissue envelope, posttrauma time, and circulation. These factors

2 viii should play a significant role in planning the surgical incision, and may dictate the repair options available to the surgeon. Closed Manipulation, Intraosseous Reduction, and Rigid Internal Fixation for Displaced Intra-Articular Calcaneal Fractures 197 Although open reduction and internal fixation for treating displaced intra-articular calcaneal fractures remain common, difficulty obtaining and maintaining both calcaneal morphology and subtalar articular surface reduction remain. In addition, open approaches induce a significant risk of wound-healing complications. For this reason, closed manipulation to restore calcaneal morphology, intra-osseous fracture reduction, and rigid locked nail fixation was developed and validated for clinical use. Conversion to an immediate primary or delayed reconstructive subtalar joint arthrodesis using the same instrumentation remains unique to this system. This article reviews the CALCANAIL surgical technique for performing operative fixation of displaced intra-articular calcaneal fractures. Sinus Tarsi Approach with Screws-Only Fixation for Displaced Intra-Articular Calcaneal Fractures 211 Tim Schepers Treatment of displaced intra-articular calcaneal fractures has changed numerous times in the last decades. Currently, less invasive surgery has reemerged and is increasingly used. The sinus tarsi approach is most commonly used. It combines the open approach to the subtalar joint with percutaneous reduction of the overall shape of the calcaneus. The results in the literature show overall similar functional outcome compared with the extended lateral approach, however with a significant reduction in wound complications. This article deals with the sinus tarsi approach in which the reduction is fixated using screws only. Indications, surgical technique, and possible pitfalls are discussed. Sinus Tarsi Approach with Subcutaneously Delivered Plate Fixation for Displaced Intra-Articular Calcaneal Fractures 225 Glenn M. Weinraub and Marissa S. David Video content accompanies this article at theclinics.com. Displaced intra-articular calcaneal fractures can be treated with open reduction and internal fixation through various methods, including the extensile lateral approach, sinus tarsi approach, percutaneous reduction and fixation, external fixation, and calcaneoplasty. Although the gold standard is the extensile lateral approach, this method has significant wound-healing complications associated with it. Literature shows that the reduction achieved through minimally invasive techniques is equal to that achieved with the extensile lateral approach, while reducing the amount of postoperative complications. This article outlines a technique that uses the sinus tarsi approach with subcutaneous plate fixation.

3 ix Role of Subtalar Arthroscopy for Displaced Intra-Articular Calcaneal Fractures 233 Chul Hyun Park Subtalar arthroscopy has an important role in enhancing the reduction of the posterior facet in percutaneous and open approaches of displaced intra-articular calcaneal fractures. In the percutaneous approach, arthroscopically assistant percutaneous approach must be selected carefully for mild-to-moderately displaced fractures. In the open approach, there is still little evidence of the utility of subtalar arthroscopy. Therefore, intraoperative arthroscopy should always be used in conjunction with fluoroscopy to achieve reduction and assess the internal fixation placement. Joint-Sparing Surgical Management of Sanders IV Displaced Intra-Articular Calcaneal Fractures 251 Displaced intra-articular calcaneal fractures represent life-altering injuries. Difficulty obtaining and maintaining calcaneal morphology and the significant risk of wound healing complications with an extensile lateral incision exist. Open reduction with internal fixation as a joint-sparing approach has been studied. Closed manipulation to restore calcaneal morphology, intraosseous fracture reduction, and rigid locked CALCANAIL fracture nail fixation have recently been applied to Sanders IV fracture patterns. Spontaneous conversion to primary subtalar joint arthrodesis using the same instrumentation remains unique to this system. This article reviews open and percutaneous approaches for joint-sparing and primary arthrodesis procedures to treat Sanders IV fracture patterns. Intraoperative Reduction Techniques for Surgical Management of Displaced Intra-Articular Calcaneal Fractures 269 James M. Cottom, Steven M. Douthett, and Kelly K. McConnell Fractures of the calcaneus are detrimental injuries, often caused by highenergy trauma. To best restore the functionality of a limb and allow normal ambulation, it is recommended to repair displaced intra-articular calcaneus fractures surgically. This article presents several methods of reduction and repair of the calcaneus. Traditionally, calcaneal fractures have been repaired through a lateral extensile incision that has been shown to have a high percentage of wound healing complications. In recent times, there has been a shift toward minimally invasive and sinus tarsi incisional approaches in the repair of calcaneus fractures. Arthroscopic and Endoscopic Management of Common Complications After Displaced Intra-Articular Calcaneal Fractures 279 Tun-Hing Lui, Xiao-hua Pan, and Yu Pan The list of late complications after calcaneal fracture that can be treated through arthroscopic and/or endoscopic approach continues to expand. The late complications of calcaneal fractures can be classified into 3 groups: (1) those causing focal hindfoot or ankle pain, (2) those causing functional deficit, and (3) those present with diffuse and poorly localized pain. Many group 1 and some group 2 complications can be managed arthroscopically and/or endoscopically. There are usually multiple coexisting

4 x sources of the pain. Careful evaluation and analysis of a problem and detailed surgical planning with combination of arthroscopic/endoscopic and open procedures are key to success. Primary or Secondary Subtalar Arthrodesis and Revision of Calcaneal Nonunion with Minimally Invasive Rigid Internal Nail Fixation for Treatment of Displaced Intra-Articular Calcaneal Fractures 295 Didier Fuentes-Viejo, Gabriel Cellarier, Philien Lauer, Patrick Simon, and Thomas Mittlmeier Primary or secondary subtalar joint arthrodesis after displaced intraarticular calcaneal fractures makes use of talocalcaneal largediameter screw fixation after an eventual correction of geometric hindfoot deformity. Despite this procedure usually having a successful functional outcome, potential complications occur, including nonunion and malalignment, with an unknown rate of loss of correction or implant migration during the healing period. Angular stable fixation of the subtalar joint arthrodesis with an interlocking nail applied in a minimally invasive technique affords maintenance of the hindfoot position until osseous healing occurs. The key steps of the surgical technique are described. Management of Calcaneal Fracture Malunion with Bone Block Distraction Arthrodesis: A Systematic Review and Meta-Analysis 307 Mitchell J. Thompson and One of the most severe complications in calcaneal fractures is a malunion. When a malunion occurs, subtalar bone block distraction arthrodesis provides restoration of calcaneal height, length, correction of varus deformity, and elimination of subtalar joint arthritis. A systematic review showed the union rate for all procedures was 95.78%. The overall complication rate was 38% for all procedures. This is the first study to categorically break down complications with statistical analysis. The data presented indicate the level of difficulty of the subtalar distraction bone block arthrodesis for calcaneal malunions and may even suggest the need for newer techniques. Wound Coverage Options for Soft Tissue Defects Following Calcaneal Fracture Management (Operative/Surgical) 323 Christopher Bibbo, Noman Siddiqui, Jessica Fink, Jake Powers, David A. Ehrlich, and Steven J. Kovach Soft tissue defects and wound healing complications related to calcaneus fractures may result in significant morbidity. The management of these soft tissue complications requires following reconstructive principles that provide the requisites for preservation of the injured limb and the maximization of function. Soft tissue complications are addressed with methods that commensurate with the degree of injury, ranging from local wound care to free flap reconstruction. With the orthoplastic approach to both bone and soft tissue plastic reconstruction, outcomes for limb salvage are greatly enhanced. This article discusses in detail the reconstructive ladder for soft tissue injuries associated with calcaneus fractures.

5 xi Salvaging the Unsalvageable Severe Malunion Deformity After Displaced Intra-Articular Calcaneal Fractures: What Options Exist? 339 Kelli L. Iceman, Mark K. Magnus, and A subset of calcaneal fractures is so severe that it may warrant primary conservative treatment. Unfortunately, nonoperative management of these fractures can lead to the development of a calcaneal malunion and cause significant patient morbidity. Surgical management of these deformities often requires increasingly complex reconstructive procedures. The goals of surgery include re-establishing calcaneal height, restoring the talocalcaneal relationship, and creating a stable, plantigrade foot. This article highlights the available surgical treatment options (including calcanectomy, calcaneal allograft transplantation, vascularized autografts, and calcaneal prostheses) for the management of severe calcaneal malunion deformities.