Minimal invasive treatmentof intra-articular calcaneal fractures

1. Minimal invasive treatment
of intra-articular calcaneal fractures
Christian Rodemund
Trauma Center Linz/Austria
Georg Mattiassich
Trauma Center Linz/Austria
Ludwig Boltzmann Institute for experimental and clinical traumatology
www.auva.at

2. This presentation should
• show our technique of
minimal invasive reduction and fixation of
intra-articular calcaneal fractures
• include some considerations for operative
minimal invasive procedures and
supposed advantages when
compared with conservative
treatment or open surgery

3. Intra-articular fractures
of the calcaneus are
severe injuries with high
risk of complications
and disability

4. Injury to joints,
length reduction and
deviation of axis
are the norm.
Multiple fragments
or comminution
are typical for these
fractures.

5. Sensitive soft tissue situation and blood supply
complicate the surgical approach
leading to delayed wound healing, skin necrosis and infection.

6. Arguments for
conservative treatment

7. • In complex dislocated fractures with multiple
fragments surgery may have no prospect of success
• Risk of skin necrosis and/or infection is high
• Excessive local swelling and wound healing problems
are to be expected
• Cases with unsatisfactory radiological results but
outcomes with moderate levels of pain are reported
• Even good reduction of the sub-talar joint often leads to
pain and secondary arthrodesis

8. Arguments for operative treatment
(especially minimal invasive technique)

9. What we can ‘always‘ achieve
Correction
• of the length
• of the axis
• of broadening
• of height
• of impingements
Reduction and fixation
of main fragments
Evacuation of the hematoma
Prevention of swelling and pain

10. Early
minimal invasive intervention
is the best prophylaxis for
skin necrosis, infection and swelling

11. The reduction of the fragments
reduces skin tension and
therefore prevent
skin necrosis and infection
Stable fixation with screws
reduces local movement and
stress and therefore reduces
pain
Small incisions prevent
complications

12. Evacuation of the
hematoma reduces the
internal pressure
During the first days it is
possible to move the broken
parts easily against each
other without preformed
adhesions
 less surgical trauma
In most cases no cast
necessary
 early mobilisation

13. Important
Sufficient extension
between talus and
the main posterior
calcaneal fragment
including
the correction of the
axis (varus)
creates space
for the central parts.

14. An extension device is necessary
Extension for reduction, space for the fragments
and stability for fixation is needed
Note: I never use a compression device

15. The bending of
the k-wires
indicate
which forces are
needed for
extension,
reduction and
fixation
Note: Leave the
extension device
until definitive
fixation

16. skin necrosis and infection

17. Early
minimal invasive intervention
Aims of procedure:
Small incisions, good reduction, good
stability, little implants, shorter surgery
time, functional rehabilitation
THE MAIN POINT

18. In simple intra-articular fractures
the aim should be
an anatomical reduction and stable fixation

19. In comminuted fractures
compression with defects and completely destroyed
sub-talar joint line can make it impossible to achieve an
anatomical result
left right

20. The aims should be to reduce/prevent
• early complications (swelling….)
• additional surgical trauma (minimal invasive)
• deviation of axis and reduced length (function)
• tilting of the talus
• impingement of the upper ankle joint (osteoarthritis)
• defect-situation subtalar (difficult arthrodesis)

21. The intention aims to prevent this outcome
6 month after trauma
secondary correction and arthrodesis is difficult and complex

22. Our surgical technique

23. Strictly standardized procedure
allows the surgeon
to focus entirely on the surgery
and avoids
stress, distractions and discussions

24. Standardized
• position of surgical table, instrument
table and image intensifier
• positioning of the patient
• surgical procedure with trained team
• instruments and implants
• X-Ray views (plantar, lateral, Broden)

25. Pre-operative adjustment
of the three X-ray views
together with your medical technical staff
Never discuss view settings during surgery
define and train

26. No movement
of patient or image intensifier
during surgery
iso-centered X-ray machine highly recommended

27. Positioning in lateral decubitus with leg in
leg holder in horizontal position

28. Positioning of the foot should be strictly in horizontal
plane, otherwise adjustment of the image intensifier
can be problematic

29. Image intensifier (iso-centric recommended)
Three views from one position
Lateral - Plantar – Broden
• The position of the machine is in
line with the plantar plane of the
foot
• The machine‘s position is fixed,
only move the C-arm to the three
defined positions
• Only possible using an iso-centric
image intensifier

30. Lateral view
Note: focus area is the talus, not the calcaneus

31. Broden view
about 45 degrees to lateral view

32. Plantar view
C-arm horizontal

33. Plantar view
manual dorsal flection of the foot to determine the axis of the
calcaneus

34. Three views
Lateral
Plantar
Broden

35. Procedure Overview
 Insertion of extension pins
 Extension using distraction device
 Reduction of varus mal-alignment and length
 Lateral incision
 Evacuation of hematoma
 Reduction of central fragments using an elevator
 K-wire for cannulated screw (4mm screws)
(sustentaculum screw)
 Reduction and retention of anterior process, tuber, etc
 K-wire positioning for fixation of axis and length
(7.3mm fully threaded screws)

36. 4 mm and 7.3 mm cannulated screws

37. Extension Device

38. Positioning of extension device

39. Positioning of extension pins
The first pin is located in the
anterior process of the talus
exactly in frontal and axial plane
The second pin is located in the
distal plantar region of the tuber calcaneus

40. Ensure the pin is
placed exactly
perpendicular to the
angulated axis using
the plantar view.
If this cannot be
achieved , varus
correction is not
possible and the
reduction
will not succeed.

42. This position allows placing the 7.3 mm screws
without removing the pins

43. Correction of varus and placement of the
medial extension device

44. Bend the k-wires – otherwise the devices may slip

45. With the device mounted and varus corrected you
can now extend to correct length and create space
for the displaced central fragments

46. On the bent k-wires, tension needed for length
correction and retaining the reduction can be seen

47. Lateral incision

48. You see the main depressed joint fragment.
Correct extension is obligatory to move this fragment to its anatomical
position.

49. Reduction of the ‘joint fragment‘

50. Reduction of the ‘joint fragment‘
Broden view Lateral view

51. Another case

52. Fixation with 4mm screw (Sustentaculum screw)
Broden view Lateral view

53. Fixation with 4mm screw (Sustentaculum screw)

54. Sustentaculum screw
placed from lateral in medio-ventral direction
to target the sustentaculum directly below the center
of the medial malleolus to stabilize the lateral joint fragment

55. Sustentaculum screw

56. Static fixation of the reduction

57. Static fixation of the reduction

58. Static fixation of the reduction

59. Static fixation of the reduction
Place the 7.3 mm screws
under extension proximal
of the calcaneus pin.
These screws provide static
fixation of reduction,
supports the joint fragment
and stabilizes the axis.
Their heads lie below
corticalic niveau and cause
no soft tissue irritation.
Pins
Pins

61. 24 hours after trauma
20 hours after surgery

62. Aftertreatment
• Sutures are removed at 10-14 days
• Weight bearing is delayed
until 6 weeks
• Weight bearing is allowed
in heel off-loading shoe
for another 6 weeks

63. Aftertreatment
• Supervised physical therapy may be beneficial,
both during the non–weight-bearing period
and during the active weight-bearing
recovery phase
• Removement of the screws is not routinely
needed or recommended
• Removement of the 7.3 mm screws is possible
under local anaesthesia

64. Aftertreatment
Minimal invasive treatment
instead of open reduction and plate fixation
might be a
significant advantage
if secondary arthrodesis of the
sub-talar joint is needed

65. Open reduction and
internal fixation
(ORIF) with a plate

66. Closed reduction and
minimal invasive
fixation with screws

67. Benefits
Removement of the screws with stab incisions
Approach to sub-talar joint for arthrodesis over short
incisions is possible (eg. Ollier’s approach)
Less surgical trauma

68. Examples
A

69. Examples
A

70. Examples B

71. Example C

72. Example
C

73. Example D

74. Example D

75. Example D

76. Example E

77. Example E

78. Example F

79. Example F

80. Example G
left
right

81. Example G
left
left
right right

82. Example H
36 year old male
patient
fall from 10 meters in
indoor-climbing
surgery one day after
trauma
6 weeks after surgery
weight bearing
allowed in heel off-
loading shoe
physical therapy

83. Example H

84. Example H
8 months after trauma -
Becouse of the
comminution anatomical
reduction was not possible
but we could achieve a
stable situation and
problem-free soft-tissues

85. Example H
Return to work as manual worker 6 month after trauma
started to climb again 7 month after trauma
moderate swelling and pain only after intensive activities
8 months after trauma

86. Example H

87. Video of procedure

88. Thank you for your attention
Christian Rodemund
Trauma Center Linz/Austria
christian.rodemund@auva.at
Georg Mattiassich
Trauma Center Linz/Austria
Ludwig Boltzmann Institute for experimental and clinical traumatology
georg.mattiassich@auva.at
www.auva.at
We would be more than happy
for your comments and questions