lecture 12 shah orif calcaneal fractures

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ORIF : Calcaneal fracture & Algorithm Dr.Rajiv Shah Foot & Ankle Orthopaedics Foot & Ankle Surgeon Vadodara, Surat, Gujarat

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Page 1: Lecture 12 shah orif calcaneal fractures

ORIF : Calcaneal fracture&Algorithm

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

Page 2: Lecture 12 shah orif calcaneal fractures

Before surgery

Learn about deformitiesHeel Position

Comminution of post.facet

Shortening/BroadeningInvolvement of CC joint

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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

Page 4: Lecture 12 shah orif calcaneal fractures

Wrinkle test

DF + EVR

Page 5: Lecture 12 shah orif calcaneal fractures

Lateral positionRadiolucent tableTourniquetC-arm in proper position

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C-ARM

SURG

ASSIST.

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Page 8: Lecture 12 shah orif calcaneal fractures

Incision:Vertical limb is taken more posteriorGentle apical curve

Page 9: Lecture 12 shah orif calcaneal fractures

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

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

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

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C F L

Peronei

Page 12: Lecture 12 shah orif calcaneal fractures

Flap retraction:3 or more bent K-wires

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14 Step Calcaneal fracture fixation surgery!!

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Step 1: Lateral wall dissection & hinging it down

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Step 2: ST pin passage

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Step 3: Removal of articular fragment

OUT ON TROLLEY

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“Reduction is started from inside out….

Beginning with medial wall

& sustantaculum reduction ”

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Step 4: Medial wall/ sustantacular reduction

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Step 5: Heel height & heel axis restoration

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Step 6: articular fragment back in reduced position

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

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

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Step 9: Restoration of Gissane angle

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

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Looks like this!!ARTICULAR REDUCTION WIRES

HEEL LEGTH RESTORING WIRE

HEEL HEIGHT RESTORING WIRES

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Step 11: Fluro check

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

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Optional step: Dry subtalar scopy

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

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

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Step 13: Repositioning of lateral wall

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Step 14: Neutralization with plate

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Fixation

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

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

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

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

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Calcaneal fracture: My algorithm

Sander’s I

Percutaneous

fixation

MIS

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Calcaneal fracture: My algorithm

Sander’s II MIS

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Sander’s III ORIF

Calcaneal fracture: My algorithm

After more experience:

MIS

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Sander’s IV

Primary Fusion

Calcaneal fracture: My algorithm

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“ 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

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That’s all…