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ORIF Calcaneum

Aims, Principles & Alternative

  1. To restore congruency of posterior facet of subtalar joint
  2. To restore height of calcaneum (and hence, Bohler’s angle)
  3. To reduce width of calcaneum
  4. To decompress sub-fibular space for peroneal tendons & prevent impingement
  5. To realign tuberosity into valgus
  6. To reduce calcaneocuboid joint, if involved
  7. Alternatives include compression dressing & early mobilisation of ankle, GAMP, manipulation with Steinmann pin (go lateral to tendo Achilles for reduction of tongue type fractures), & Ex-Fix

Indications

  • Displaced intra-articular fracture (Sanders II or III), in a (young) healthy, non-smoker with normal ambulatory function & a sensate limb, with swelling reduced (wrinkle sign), & no fracture blisters (ie. usually 10-14 days post injury)
  • Sanders IV fractures usually treated closed or with ORIF & primary arthrodesis
  • Open fractures should be treated with initial debridement, especially of medial spike, & then delay 2-3 weeks for wound to stabilise.

Contraindications

  • Undisplaced or severely comminuted fracture, insensate limb (DM, other neuropathy, trauma), PVD, smoker, limited ambulation, inexperienced surgeon.

Preop

  • Xray- Lateral foot, AP/obl foot to assess anterior process & calc-cuboid joint, axial (Harris) view to assess varus alignment & heel width, Broden view to assess posterior facet congruency
  • CT in axial plane & semicoronal plane (perpendicular to posterior facet of calcaneum)
  • Consent including
  • contract to stop smoking, wound / deep infection, subtalar arthritis, calcaneo-cuboid arthritis, sural nerve / peroneal tendon injury

Technique

  • Tubigrip, elevation, analgesia, ice, CT, monitor for compartment syndrome. Discharge when comfortable & review skin for blisters (bad) & wrinkles (good) at 2 weeks. More difficult, but possible up to 5 weeks
  • GA / regional, lateral, IV anti’s, tourniquet, prep & drape leg free
  • L shaped incision with apex at heel tip & horizontal limb along junction of plantar skin & lateral heel skin, vertical limb midway between tendo Achilles & lateral malleolus. Straight down to bone, taking care to dissect out sural nerve at proximal & distal ends
  • Gently retract flap & perform subperiosteal dissection along lateral wall
  • Hold flap out of the way with K wires in talus, lateral malleolus & cuboid. Expose entire lateral wall, posterior facet & calcaneo-cuboid joint
  • Reflect lateral wall with osteotomy to expose posterior facet & medial side from within bone. Using a Steinmann pin in tuberosity fragment, distract it inferiorly, then lever into valgus, & then translate it medially
  • Use K wires to temporarily fix fragments, building onto medial wall & sustentacular fragment
  • Elevate the depressed posterior facet & pack the cavity with autologous BG or cement or bone substitute. Check reduction with II before replacing lateral wall
  • Then fix with low profile plate, 3.5 mm cortical screws, & extra screws if needed, directed into sustentaculum & buttressing posterior facet up
  • Most posterior screw into thickened bone at posterior aspect of calcaneum & most anterior screw into calcaneo-cuboid subchondral bone. Check with II that posterior facet reduced & heel not in varus
  • Close over drain. BKPoP slab.
  • If Sanders IV, carry out ORIF as above. May need to use tricortical iliac crest BG for large defects. Then use a burr to remove cartilage & subchondral bone from posterior facets of calcaneum & talus. Fill defect with autologous BG, & fuse with 6.5 mm cancellous screw from tip of heel up into talar neck. BKPoP NWB until union (10-12 weeks)

Postop

  • Remove drain at 24 - 48 hours. Check wound healing at 5 - 7 days, remove splint & allow active ROM ankle & subtalar joints. Leave sutures in for 3 weeks. NWB for 12 weeks. Use CAM walker in between physio sessions
  • ? R/O metal after 12 months.

Results

  • Sanders
    • Type II 86% anatomical reduction, 73% good or excellent clinically
    • Type III 60% anatomical reduction, 70% good or excellent clinically
    • Type IV 73% failure

Complications

  • General systemic
  • General local - wound necrosis, dehiscence & infection, DVT
  • Specific – loss of position (early WB), malreduction, sural nerve & peroneal tendon injury
  • Delayed – posttraumatic arthritis, lateral impingement ± peroneal tendon problems, anterior ankle impingement, CRPS
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