Minimally Invasive Calcaneus ORIF: The When and the How

Pascale Thibaudeau, M.D.C.M., FRCSC
Clinical Fellow, University of Ottawa
Ottawa, ON

Greg Berry, M.D.C.M., FRCSC
Assistant Professor, McGill University
Montreal, QC

The current gold standard for operative treatment of displaced intra-articular calcaneal fractures (DIACFs) is open reduction and internal fixation through an extensile lateral approach. The goals are to obtain anatomic reduction of the articular surfaces, rigid fixation and restoration of the overall extra-articular anatomy, including height, width, and coronal alignment. However, the extensile lateral approach carries a significant risk for wound complications. This is further complicated by the limited options for soft tissue flaps in the foot. Additional problems such as sural nerve injury and peroneal tendon irritation and subluxation have also been reported.

In an attempt to mitigate these risks, several authors have developed less invasive techniques for fixation of DIACFs. Tornetta described an all-percutaneous technique for reduction and fixation of tongue-type fractures, which he found most successful in Sanders IIC fractures1. Other minimally invasive techniques include external fixation, arthroscopic-assisted reduction, reduction through small medial, lateral, posterior or combined incisions, and, more recently, balloon kyphoplasty-assisted reduction of a depressed posterior facet. Our favoured technique employs a sinus tarsi approach and screw fixation. This approach affords good direct visualization of the posterior facet, particularly the anterior and lateral aspects, while maintaining a good vascular bed over the calcaneus and minimizing dead space. Any displacement involving the anterior process can also be addressed through this incision. Indirect reduction of any tuberosity displacement is performed using the same maneuvers as in an open approach with fluoroscopy used to assess accuracy of reduction.

Although high-quality studies are lacking, case series2-4 and retrospective cohort studies5,6 have shown good results with this technique, with functional outcomes comparable to those of ORIF through an extensile lateral approach. Additionally, wound complications with the sinus tarsi approach appear to be significantly lower, with rates ranging from 0 to 6%2-6, as compared to 11 to 25% with the extensile lateral approach7-9. Our recent review of 25 patients treated using this technique showed a 0% wound complication rate.

Indications
In our experience, the sinus tarsi approach can be used in most Sanders II and some Sanders III calcaneal fractures, and in both joint depression and tongue-type variants. Relative contraindications include severe soft tissue swelling, blistering over the operative site, Sanders IV fractures, and fractures with extensive comminution of the anterior process, such that screw fixation of the tuberosity to the anterior process would be impossible. Additionally, one must carefully weigh the risks and benefits of operative fixation in patients predisposed to wound complications, such as those with peripheral vascular disease, diabetes, or a smoking history.

berry1
Figure 1. Lateral sinus tarsi approach using a headlamp for visualization. Dotted line represents skin markings for extensile approach. A Schantz pin is placed in the postero-lateral tuberosity for indirect tuberosity reduction and two guide wires hold the reduction in place.

Technique
Using a beanbag, the patient is placed in the lateral decubitus position with the affected extremity facing up. The fluoroscopy unit is positioned such that lateral, axial and Broden views can be easily obtained. A headlamp may be advantageous to view the articular surface adequately. The skin incision begins one cm distal to the fibula and extends three to four cm distally towards the base of the fourth metatarsal. Blunt dissection is performed and the sural nerve and peroneal tendons are reflected plantar-ward. The distal extent depends on whether there is involvement of the anterior process. The displaced lateral fragment of the posterior facet should now be visible. Following exposure, a Schanz pin placed in the posterior aspect of the tuberosity, from lateral to medial. The knee is flexed to release tension on the gastro-soleus muscle and indirect reduction of the tuberosity is performed, restoring height and length and bringing the tuberosity out of varus. The tuberosity is held provisionally with 2.5 mm guide wires directed from the posterior heel to the anterior process, skirting the undersurface of the angle of Gissane. Once the extra-articular displacement has been corrected, the articular component is reduced under direct vision. The reduction is held temporarily with K-wires and adequacy of reduction of all components of the fracture is verified visually and using Broden and axial heel views. One or two 2.7/3.5 mm screws are then placed across the posterior facet in a lag fashion from lateral to medial. Partially threaded 7.0 /7.3 mm cannulated screws are inserted over the guide wires. The wound is closed in layers and the foot is immobilized in a well-padded three-sided slab and kept elevated for the following week. Once the wound has healed (typically at seven to ten days) the patient begins ROM exercises of the foot and ankle. The patient remains touch weight-bearing for a total of eight to 12 weeks.

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Figure 2. Lateral and axial radiographs highlighting articular and tuberosity reduction and fixation construct.

In summary, the sinus tarsi approach is useful in a large subset of DIACFs, mainly Sanders II and III patterns. This appears to significantly minimize the risk of wound complication and infection associated with the extensile approach while providing similar or improved functional outcome. A prospective randomized trial is being prepared to clarify the role of this technique in the treatment of calcaneal fractures.

References

  1. Tornetta P. Percutaneous treatment of calcaneal fractures. Clin Orthop Relat Res 2000;(375):91-96.
  2. Gupta A, Ghalambor N., Nihal A., Trepman E. The modified Palmer lateral approach for calcaneal fractures: wound healing and postoperative computed tomographic evaluation of fracture reduction. Foot Ankle Int 2003;24:744-753.
  3. Hospodar P., Guzman C., Johnson P., Uhl R. Treatment of displaced calcaneus fractures using a minimally invasive sinus tarsi approach. Orthopaedics 2008;31:1112-1117.
  4. Spagnolo R., Bonalumi M., Pace F., Capitani D. Calcaneus fractures, results of the sinus tarsi approach: 4 years of experience. Eur J Orthop Surg Traumatol 2010;20:37-42.
  5. Kline A.J., Anderson R.B., Davis W.H., Jones C.P., Cohen B.E. Minimally invasive technique versus and extensile lateral approach for intra-articular calcaneal fractures. Foot Ankle Int 2013;34(6):773-780.
  6. Weber M., Lehmann O., Sagesser D., Krause F. Limited open reduction and internal fixation of displaced intra-articular fractures of the calcaneum. J Bone Joint Surg Br 2008;90:1608-1616.
  7. Folk J.W., Starr A.J., Early J.S. Early Wound Complications of Operative Treatment of Calcaneus Fractures: analysis of 190 fractures. J Orthop Trauma 1999;13(5):369-372.
  8. Harvey E.J., Gjujic L., Early J.S., Benirschke S.K., Sangeorzan B.J. Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach. Foot Ankle Int 2001;22(11):868-873.
  9. Howard J.L., Buckley R., McCormack R., Pate G., Leighton R., Petrie D., Galpin R. Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 2003;17(4):241-249.

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