CALCANEAL FRACTURES PPT and JOURNAL.pptx

Calcaneal fracture ppt with Journal club
Comparative analysis between percutaneous reduction and Sinus tarsi approach for displaced intra articulate calcaneal fracture

1. Topic – Calcaneal Fractures Moderator – Dr. Satish S Presenter – Dr. Karthik M V

2. ANATOMY Calcaneus – Largest tarsal bone It has 4 articulating surfaces – 3 Superior, 1 anterior The superior Surface articulates with talus to form Subtalar joint The triangular anterior Surface articulates with Cuboid

3. Posterior facet of Calcaneus Largest Facet Major weight bearing facet Separated by groove from Middle and anterior facet – Calcaneus Sulcus Canal formed between Calcaneal sulcus and talus – Sinus tarsi Middle facet of Calcaneus Supported by Sustentaculum tali and articulates with medial facet of talus Anterior Calcaneal facet Articulates with anterior facet of talus and supported by Calcaneus beak

4. Medial Surface Sustentaculum tali Projects Medially and supports the Neck of talus FHL tendon Passes Beneath the groove Talus is held to Calcaneus by interosseous ligament and talocalcaneal ligaments

5. Lateral Surface Flat and Subcutaneous Peroneal tubercle attachment to Calcaneofibular ligament The peroneal tendons passes laterally between the calcaneus and lateral malleolus Achilles tendon inserted to Posterior tuberosity

6. Posterior Surface

7. Calcaneus fractures Most Commonly fractured tarsal bone 60 % Accounts for 1-2% of all fractures 60 – 75 % are intra articular fractures Male-to-female ratio of 3:1 Peak incidence – 20 – 30 years Associated with Spine injuries (Dorsa – Lumbar junction)

8. Mechanism of injury Axial Loading Fall from Height Responsible for intra articular fractures Talus is driven into calcaneus ( Primary fracture line) Motor vehicle accidents Accelerator or brake pedal impacts the plantar aspect of the foot Twisting injuries Produce Extra – articular fractures

9. Calcaneal tuberosity fracture Most common in Diabetes Poor bone quality / osteoporosis Avulsion of tendoachilles Violent contraction of Tendoachilles with forced Dorsiflexion

10. Clinical features Ecchymosis, Swelling, Haematoma Heel is Shortened and widened Lack of heel Cord continuity Open Fractures

11. Classifications Essex- Lopresti classification Extra – Articular Fractures Anterior process : fractures occur after a twisting fall and are often misdiagnosed ankle sprain Tuberosity fractures : Open beak or avulsion type fracture Sustentacular fractures : These may be missed taken for a medial ankle sprain.

12. Intra – Articular Fractures Primary fracture line of Palmar The inferior surface of the talus strikes the posterior facet like an axe Splitting it obliquely into two fragments Fracture starts in the tarsal sinus at the crucial angle of Gissane on the lateral wall Propagates posteromedially across the posterior facet until it reaches the medial wall behind the sustentaculum tali

13. This results in two fragments: Anteromedial fragment bearing the sustentaculum, anterior and medial facets, and the remaining medial part of the posterior facet. This is often termed the constant fragment, as it holds its anatomical relationship with the talus. P osterolateral fragment bearing the tuberosity and lateral portion of the posterior facet, which displaces to become shortened and lateralized

14. Secondary fracture lines A secondary line emanates from the first, splitting the posterolateral fragment into two pieces. There are two types: Tongue type: The secondary fracture line passes backwards and splits the tuberosity into two pieces The superior fragment has the appearance of a tongue Joint depression: The secondary line travels superiorly and detaches the posterior facet from the tuberosity. posterior facet, which is now free of any attachment, can be driven downwards into the substance of the calcaneus

15. Tongue type Joint depression type

16. Sander’s Classification The classification describes the number and position of these fracture line(s) through the posterior facet, as seen on CT scan. The number of fragments is first indicated by a numeral: The location of the primary fracture line(s) through the posterior facet is then indicated by a letter: A . a fracture through the lateral portion of the posterior facet B . a fracture through the middle of the posterior facet C . a fracture passing medially, at the neck of the sustentaculum .

17. Beavis Classification

18. Radiological Evaluation

19. X-Ray Ankle Lateral View The Böhler (tuber) angle is composed of a line drawn from the highest point of the anterior process of the calcaneus to the highest point of the posterior facet and a line drawn tangential from the posterior facet to the superior edge of the tuberosity. The angle is normally between 20 and 40 degrees A decrease in this angle indicates that the weight bearing posterior facet of the calcaneus has collapsed, thereby shifting body weight anteriorly

20. X-Ray Ankle Lateral View The Gissane (crucial) angle is formed by two strong cortical struts extending laterally, one along the lateral margin of the posterior facet and the other extending anterior to the beak of the calcaneus. These cortical struts form an obtuse angle usually between 105 and 135 degrees Visualized directly beneath the lateral process of the talus; An increase in this angle indicates collapse of the posterior facet

21. X - Rays

22. Harris Axial View foot in dorsiflexion and the beam angled at 45 degrees cephalad Visualization of Subtalar joint Loss of height Increased width Angulation of tuberosity fragment

23. Broden’s View Leg is internally rotated 20 degree Ankle in neutral Beam is directed 10/20/30/40 degree centered over Lateral malleolus Demonstrates articular surface of Posterior Facet Useful for intra – op reduction of Posterior Facet

24. Represents subtalar incongruity Indicates Partial separation of Posterior facet from Sustentaculum

25. The name "lover's fracture" is derived from the fact that a suitor may jump from great heights while trying to escape from the lover's spouse 

26. CT Scan Sagittal Section Coronal Section

27. Treatment Non Operative Management Below knee Slab/ Cast immobilisation for 2-3 months Non weight bearing mobilisation Initiate early ROM Indications Nondisplaced or minimally displaced extra-articular fractures Nondisplaced intra-articular fractures Anterior process fractures with less than 25% involvement of the calcaneal–cuboid articulation Sander’s type 1 Minimally displaced tuberosity fracture <1cm

28. Operative Management Indications Displaced intra-articular fractures involving the posterior facet Anterior process of the calcaneus fractures with >25% involvement of the calcaneal cuboid articulation Displaced fractures of the calcaneal tuberosity, with or without skin compromise Fracture-dislocations of the calcaneus Open fractures of the calcaneus Timing of surgery should be performed within the initial 3 weeks of injury , before early fracture consolidation. Surgery should not be attempted until swelling in the foot and ankle has adequately dissipated , as indicated by the reappearance of skin wrinkles

29. Treatment options Open reduction internal fixation Closed reduction internal fixation Percutaneous External fixation Primary Fusion

30. Approaches Position Lateral decubitus Approaches Extended Lateral L-Shaped Incision Sinus tarsi approach Medial approach

31. Extended lateral approach Based on Lateral calcaneal branch of peroneal artery Vertical incision – b/w Posterior fibula and Achilles tendon Horizontal incision – till base of 5 th Metatarsal More inferior incision protects Sural nerve Provides access to Subtalar and calcaneo-cuboid joint

32. Full thickness skin, Soft tissue and periosteal flaps developed Sural nerve and Peroneal tendons retracted Superiorly Lateral calcaneal wall visualised Fracture opened and medial wall reduced Tuberosity reduction done under direct visualisation Provisional fixation with K-wires Definitive fixation with Screws / Plates Associated with high rate of Wound complications

33. Sinus tarsi approach Minimally invasive incision Reduces soft tissue dissection Incision Tip of fibula to base of 4 th Metatarsal 2-4cm incision Lower incidence of Sural nerve injury Same incision for Subtalar arthrodesis Decreased Surgical time Decreased wound complications

34. Medial approach Incision – tip of medial malleoli to Naviculocuneiform joint Interval created between Neurovascular bundle and FHL to access Sustentaculum tali

35. Reduction technique

36. Intra-articular fractures Operative management Aims to Restore the congruity of the posterior facet articular surface Restore the width and height of the calcaneus Correct Varus malalignments Restoration of Bohler’s angle

37. Percutaneous Fixation Tongue type of fractures Essex Lopresti Manuever

38. Primary Subtalar arthrodesis Performed in highly comminuted Sander’s type 4 fractures High rate of secondary fusion with these type of injuries Avoids treatment cost Techniques Sinus tarsi approach / extensile lateral approach Fracture reduction done Subtalar articular cartilage denuded till Subchondral bone bleed CC screws applied from posterior calcaneal tuberosity to talar dome Lateral plate fixation to hold reduction

39. Calcaneal tuberosity fractures Patient positioned prone position Posterior midline incision Fracture fragment mobilised and debrided Plantar flexion of foot aids in reduction Fixation Lag screws TBW in figure of 8 manner Suture fixation – Krackow Sutures Passing through bone tunnels

40. Complications Wound Complications Wound dehiscence/necrosis: most common at the angle of incision Posttraumatic arthritis (subtalar or calcaneocuboid) require subtalar or triple arthrodesis. Peroneal tendonitis : This is generally seen following nonoperative treatment and results from lateral impingement. Sural nerve injury : This may occur in up to 15% of operative cases using a lateral approach. Compartment Syndrome – result in Claw toes

41. JOURNAL CLUB RESENTATION

42. TITLE TOPIC – Comparison between Percutaneous Screw Fixation and Plate Fixation via Sinus Tarsi Approach for Calcaneal Fractures: An 8–10-Year Follow-up Study Authors : Qi-hao Weng, Gao-le Dai, Qi- ming Tu, Yang Liu. Place of Study : Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University and The Second School of Medicine, Wenzhou Medical University, Wenzhou, China Date of Publication : 01/02/2020 Journal : Journal of Orthopaedic Surgery

43. Introduction Approximately 75% of calcaneal fractures are intra articular fractures . Treatment of displaced intra-articular calcaneal fractures (DIACF) remains controversial Past 15–20 years, further in-depth understanding has been gained of the mechanism of intra-articular fractures of the calcaneus; coupled with the improvement in surgical techniques and implants standard treatment for DIACF, open reduction and internal fixation ( ORIF ) via the extensile lateral approach (ELA) has been widely accepted and established

44. The skin of the lateral calcaneal wall is thin and vulnerable to injury, wound complications remain a major concern. Complications mainly include wound edge necrosis, dehiscence , hematoma, infection, and sural nerve injury. Many authors have proposed closed reduction and minimally invasive internal fixation to reduce the impact of wound complications. As one of the most popular and effective minimally invasive surgical methods, the sinus tarsi approach (STA) can not only fully expose the posterior facet joint and the anterolateral segment but also reduce the incidence of postoperative wound complications

45. The purpose of this study was To evaluate the long-term therapeutic effects of each of the two surgical methods To compare the long-term foot function scores of two minimally invasive methods To compare the incidence of postoperative complications of the two methods To evaluate anatomical restoration of the calcaneus under the two methods with X-ray or CT measurement

46. Materials and Methods Type of study - retrospective, randomized Duration - June 2009 to November 2013 with DIACF Sample Size – 150 Cases

47. Inclusion Criteria DIACF including Sanders types II and III Closed fracture Unilateral fracture No history of smoking or no smoking during hospitalization Follow-up time is not less than 8 years.

48. Exclusion Criteria Clear surgical contraindications (severe cardiovascular and cerebrovascular diseases) Local or systemic infection symptoms Diagnosis of diabetes or lower extremity vascular disease Sanders type IV or open fracture patients.

49. Surgical Method – Percutaneous Reduction Under the guidance of C-arm fluoroscopy, a 3.5-mm Kirschner wire (K-wire) was inserted percutaneously through the lateral aspect of the Achilles tendon at the upper posterior margin of the calcaneus. The tip of the K-wire was stopped at approximately 1 cm below the posterior facet of the subtalar joint Then the calcaneus and midfoot were bent towards the plantar side with the help of a K-wire.

50. Surgical Method – Percutaneous Reduction Posterior facet of the subtalar joint was moved closer to the sustentaculum tali by adjusting the rearfoot valgus. Under C-arm 1–2 1.5 mm K-wire was then drilled medially from the posterior articular surface of the lateral bone block to transversely fix the fracture block of the sustentaculum tali. One K-wire was drilled from the calcaneal tubercle towards the sustentaculum tali Bohler’s angle, Gissane’s angle, and the length and height of the calcaneus were evaluated using the C-arm X-ray.

51. Sinus Tarsi Approach 5–7-cm incision parallel to the sole of the foot was made from the tip of the fibula to the lateral wall bone of the anterior process of the calcaneus. fracture fragments of the joint were repositioned by adjusting with a Steinmann pin. When a sufficient reduction by fluoroscopy under C-arm X-ray machine was confirmed, a 2–3 K-wire was temporarily fixed. The plate was inserted through the incision. Following the plate insertion, the screws were fixed through the incision

52. Postoperative Treatment and Follow-up No need for plaster cast fixation after surgery. Partial weight-bearing of the rear foot with crutches were initiated 6 to 8 weeks after surgery . After 12 weeks of surgery, fracture healing was evaluated by X-ray image, after which the patients were allowed to begin full weight-bearing All patients were followed up for an average of 8.7 (range, 8.0–10.0) years.

53. Clinical Outcome The AOFAS hindfoot scores and the postoperative wound related complications were recorded. Lateral and axial X-ray or CT scans were performed 1 day after the operation to assess the reduction of the fracture. Bohler’s angle, Gissane’s angle, the height, the width, and the length of the calcaneus were measured in each follow ups

54. A total score less than 50 - poor 50–74 - fair 75–89 - good 90–100 - excellent

55. Results there was no significant difference in the AOFAS score between the PR group and the STA group at 1, 3, 5, and 8 years of follow-up (P > 0.05) Functional Outcome

56. Postoperative Complications 13 patients (3 in the PR group and 10 in the STA group) had wound healing complications The incidence of wound complications was 3.8% in the PR group and 13.9% in the STA group (P = 0.041). During the follow up, 2 patients developed subtalar arthritis (1 case in the PR group and 1 case in the STA group, P = 1.00). Both patients underwent subtalar arthrodesis. Overall, the incidence of complications was 12.8% in the PR group and 27.8% in the STA group (P = 0.026).

57. Radiographic Evaluation T here was no significant difference in the calcaneal Bohler’s angle, Gissane’s angle, height, and length between the PR and STA groups during the pre operation, post operation, and follow-up period (P > 0.05) The calcaneal width was smaller in the STA group than in the PR group after the operation and during the follow-up period (P < 0.05)

58. Discussion Calcaneal fractures account for 2.84% of all fractures and approximately 75% of them are DIACF The ELA is the most common approach for ORIF of DIACF High incidence of postoperative complications , including wound edge necrosis, splitting, hematoma, or deep infection To reduce wound complications, many operations for minimally invasive reduction and fixation of DIACF have been developed. In recent 30 years, percutaneous fixation, external fixation, arthroscopically assisted fixation

59. A Failed Case in the Study The patient had a Sanders type III calcaneal fracture. The length, height, and width of the calcaneus had not been restored and the articular surface had not been restored satisfactorily.

60. Limitations of the Study Small Sample Size The data obtained in this study mainly depend on the records of follow-up cases no multicenter randomized controlled trials were performed

61. Conclusion This study involved a long-term follow-up comparing PR and screw fixation and plate fixation via STA for patients with DIACF. STA was found to be superior to PR in terms of the recovery of calcaneal width , providing more stable fixation for Sanders III fractures. PR was found to be more effective in reducing wound complications The two techniques had similar AOFAS scores after the operation.

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