Download Minimally Invasive Calcaneus Fracture Fixation

oriented fibers of the aponeurosis are separated to expose muscle fibers of the flexor digitorum brevis
muscle. These muscle fibers are then separated and retracted to expose the flexor digitorum longus
tendon.
The identity of the tendon is verified by applying a pulling tension on the tendon through the proximal
wound in the hindfoot and assessing transmission of the tension distally to the tendon identified in the
midfoot and at the same time observing maximal flexion either in lesser toes or the great toe. The tendon
is then cut sharply in the midfoot and the cut end pulled proximally through the wound in the hindfoot
region.
1. Mann, RA; Thompson, FM: Rupture of the posterior tibial tendon causing flat foot. Surgical
treatment. J. Bone Joint Surg 67A: 556-561,1985.
2. Panchbhavi VK: Chronic Achilles Tendon repair with Flexor Hallucis Longus Tendon harvested
using a Minimally Invasive Technique. Techniques in Foot and Ankle Surgery 6(2) 123-129;
2007
3. Panchbhavi VK, Yang J, Vallurapalli S: Minimally Invasive Method of Harvesting Flexor
Digitorum Longus Tendon: A Cadaver Study. Foot Ankle Int. 29 (1) 42-48; 2008
 10:20-10:30 am - Minimally Invasive Calcaneus Fracture Fixation: European
Experience
Stefan Rammelt, MD, PhD
Dresden, Germany
Percutaneous reduction and screw fixation of calcaneal fractures aims at reducing the risk of
wound complications and postoperative scarring as compared with open reduction via extended
approaches. It is a suitable treatment for extra-articular and selected intra-articular calcaneus
fractures provided anatomical reduction of the posterior calcaneal facet can be achieved.
The method of closed reduction with percutaneous pin leverage (”Essex-Lopresti reduction” in the
English-speaking literature) was introduced by the German surgeon Westhues in 19341. This method has
found reappraisal for less severe fracture patterns, like Sanders type IIC fractures, with the posterior facet
being displaced as a whole2. When applying this method to Sanders type IIA and IIB fractures, anatomic
reduction of the posterior facet should be controlled with intra-operative subtalar arthroscopy3 or 3D
fluoroscopy because subtalar joint congruity is highly predictive of the functional outcome4.
Percutaneous reduction and screw fixation may also be a treatment alternative even in more severe
fracture patterns (Sanders types III and IV) in patients with contraindications to open reduction and plate
fixation (i. e. critical soft tissues, immunodeficiency, high perioperative risk)4.
Ideally, surgery should be performed within 3 to 5 days after the injury before the formation of excessive
clots and fibrous adhesions makes percutaneous reduction difficult. Patients should be compliant with the
postoperative protocol of partial weight-bearing and early active range of motion exercises for the ankle
and subtalar joints in order to benefit from this type of treatment. Hardware removal is required for
prominent screw heads only.
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A
B
Fig. 1 (A) Reduction of the tuberosity fragment is achieved out with percutaneous leverage through a
Schanz screw with handle (1). The amount of correction of the tuberosity-joint-angle (Böhler’s angle) and
varus or valgus deformity is controlled fluoroscopically. The lateral posterior facet fragment is
manipulated percutaneously with a smooth or sharp elevator (2), a pestle (3), or Kirschner wires. The
lateral posterior facet fragment is disimpacted and tilted gently and then aligned to the medial fragment
of the posterior facet at the joint level under arthroscopic control (4). (B) The fragments are fixed with
three to six cannulated cortical screws introduced percutaneously via stab incisions (adapted from5).
A
B
Fig. 2 Arthroscopic control of percutaneous reduction and the corresponding coronal CT-scans before
(A) and after (B) reduction.
If anatomical reduction by means of percutaneous manipulation is impossible because of deep impaction
of the posterior facet fragment or soft tissue interposition, open reduction via a lateral approach becomes
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necessary. To avoid severe soft tissue problems, the surgeon should not be overly zealous to achieve
percuataneous reduction and increase swelling with repeated frustrating reduction attempts before
converting to open reduction.
Starting in 1998, our group performed percutaneous reduction and screw fixation in 61 patients with
Sanders Type II calcaneal fractures. In 33 displaced fractures through the posterior facet (Types IIA and
IIB), anatomic reduction of the subtalar joint was confirmed arthroscopically.6 No wound complications or
infections were seen. A prominent screw was removed in two patients, another patient underwent
arthroscopic arthrolysis after one year. When comparing these patients to a historic cohort of 18 patients
treated with open reduction and internal fixation via an extended lateral apporach for Type II calcaneal
fractures, the AOFAS scores after two years were comparable (92.1 vs. 88.2) and the calcaneal shape
had been restored in both groups. The patients from the percutanous treatment group had significantly
less time off from work and better range of motion at the subtalar joint at follow-up.6
Other European authors have reported favourable results with percutaneous reduction and fixation
regardless of the type of fracture. Methods include external fixation with a three-point distractor,7-10
Steinmann pins, and Kirschner wires.11-13 Because of the different outcome measurements, no general
conclusions can be drawn. Historically, Kirschner wire fixation resulted in articular step-offs in plain
radiographs in 37% and some loss of reduction in 71% of cases.11 Although these numbers could be
reduced substantially in the more recent series, percutaneous reduction of severely displaced, complex
fractures carries the considerable risk of residual joint incongruity with an inferior functional
outcome.4,10,14
References
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Westhues H. Eine neue Behandlungsmethode der Calcaneusfrakturen. Zugleich ein Vorschlag zur Behandlung
der Talusfrakturen. Zentralbl Chir 1935;35:995-1002.
Tornetta P, 3rd. The Essex-Lopresti reduction for calcaneal fractures revisited. J Orthop Trauma 1998;12:46973.
Rammelt S, Gavlik JM, Barthel S, Zwipp H. The value of subtalar arthroscopy in the management of intraarticular calcaneus fractures. Foot Ankle Int 2002;23:906-16.
Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies and recent developments. Injury 2004;35:443-61.
Zwipp H, Rammelt S, Gavlik JM. Calcaneus fractures: Open reduction and internal fixation. In: Wülker N,
Cracciolo A, Stephens M: An Atlas of Foot and Ankle Surgery, 2nd ed., London, Martin Dunitz Publishers 2005,
pp. 247-260
Rammelt S, Amlang M, Barthel S, Gavlik JM, Zwipp H. Percutaneous Treatment of Less Severe Intraarticular
Calcaneal Fractures. Clin Orthop Relat Res 2009 (in press)
Forgon M, Zadravecz G. Closed reduction and percutaneus osteosynthesis: technique and results in 265
calcaneal fractures. In: Tscherne H, Schatzker J, eds. Major fractures of the pilon, the talus and the calcaneus.
Berlin, Heidelberg, New York: Springer Verlag 1993, pp. 207-13.
Magnan B, Bortolazzi R, Marangon A, Marino M, Dall'Oca C, Bartolozzi P. External fixation for displaced intraarticular fractures of the calcaneum. J Bone Joint Surg Br 2006;88:1474-1479.
Schepers T, Vogels LM, Schipper IB, Patka P. Percutaneous reduction and fixation of intraarticular calcaneal
fractures. Oper Orthop Traumatol 2008;20:168-175.
Walde TA, Sauer B, Degreif J, Walde HJ. Closed reduction and percutaneous Kirschner wire fixation for the
treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results
after 2-10 years. Arch Orthop Trauma Surg 2008;128:585-591.
Buch J, Blauensteiner W, Scherafati T, Vischer HM, Fischer W. Conservative treatment of calcaneus fracture
versus repositioning and percutaneous bore wire fixation. A comparison of 2 methods [in German].
Unfallchirurg 1989;92:595-603.
Poigenfürst J, Buch J. Treatment of severe fractures of the calcaneus with repositioning and percutaneous wire
fixation [in German]. Unfallchirurg 1988;91:493-501.
Stulik J, Stehlik J, Rysavy M, Wozniak A. Minimally-invasive treatment of intra-articular fractures of the
calcaneum. J Bone Joint Surg Br 2006;88:1634-41.
Crosby LA, Fitzgibbons T. Intraarticular calcaneal fractures: results of closed treatment. Clin Orthop Relat Res
1993;290:47-54.
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