lecture 12 shah orif calcaneal fractures

ORIF : Calcaneal fracture&Algorithm

Dr.Rajiv ShahFoot & Ankle OrthopaedicsFoot & Ankle SurgeonVadodara, Surat, Gujarat

Before surgery

Learn about deformitiesHeel Position

Comminution of post.facet

Shortening/BroadeningInvolvement of CC joint

When?Timing is the key!!

Blisters: delay ORIF Wait up to 3-7 days Use of elevation, ice,

compression, drugs, foot pump

Beyond 3 weeks –treat as calcaneal malunion!

Wrinkle sign

Wrinkle test

DF + EVR

Lateral positionRadiolucent tableTourniquetC-arm in proper position

C-ARM

SURG

ASSIST.

Incision:Vertical limb is taken more posteriorGentle apical curve

Extended lateral approachFlap based on lateral calcaneal arteryVertical & horizontal limbs – gentle apical curve

Flap lifting:CFL, Sural nerve & Peronei goes in side the flap

No- touch flap handling with plain forceps/blunt skin hooks

C F L

Peronei

Flap retraction:3 or more bent K-wires

14 Step Calcaneal fracture fixation surgery!!

Step 1: Lateral wall dissection & hinging it down

Step 2: ST pin passage

Step 3: Removal of articular fragment

OUT ON TROLLEY

“Reduction is started from inside out….

Beginning with medial wall

& sustantaculum reduction ”

Step 4: Medial wall/ sustantacular reduction

Step 5: Heel height & heel axis restoration

Step 6: articular fragment back in reduced position

Step 7: Articular fragment fixation with 1/2 temporary k-wires

Step 8: Fixation of heel tuberosity with proximal fragment with two temporary k-wires

Step 9: Restoration of Gissane angle

Step 10: Heel length restoration & temporary k-wire fixation from heel tuberosity to anterior fragment

Looks like this!!ARTICULAR REDUCTION WIRES

HEEL LEGTH RESTORING WIRE

HEEL HEIGHT RESTORING WIRES

Step 11: Fluro check

AP = LATLAT = AxialBroden’s – 10,20,30,40

Optional step: Dry subtalar scopy

Step 12: Articular fragment fixation: outside the plate or through the plateone or two 5mm CC screws

Optional step: Void filling with bone grafts or bone graft substitutes

Step 13: Repositioning of lateral wall

Step 14: Neutralization with plate

Fixation

Closure Two layersStarts from ends & goes towards apex (to avoid tension at apex)Knots outside the flapdrain??

There are many controversial views in literature with respect to treatment of calcaneal fractures: ORIF? Conservative care?

Out of all controversial issues MIS is emerging as the best modality of care

There is no controversy that all Sander’s type IV cases requires ORIF plus primary subtalar fusion

Calcaneal fracture: My algorithm

Sander’s I

Percutaneous

fixation

MIS

Calcaneal fracture: My algorithm

Sander’s II MIS

Sander’s III ORIF

Calcaneal fracture: My algorithm

After more experience:

MIS

Sander’s IV

Primary Fusion

Calcaneal fracture: My algorithm

“ Try to correct as much damage as possible in the acute phase with surgery as late salvage procedures are quite difficult with absolutely uncertain results !! ”

Sander

That’s all…