lecture 12 shah orif calcaneal fractures
TRANSCRIPT
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…