ortho journal club 7 by dr saumya agarwal
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Percutaneous Calcaneoplasty in Displaced Intraarticular Calcaneal
FracturesJ Orthopaed Traumatol
Francesco Biggi
Level of evidence IIb
PRESENTER : Dr SAUMYA AGARWAL
Junior resident Dept of Orthopaedics J.N. Medical College and Dr. Prabhakar Kore Hospital and MRC, Belgaum
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INTRODUCTION• Calcaneum is the most frequently fractured
tarsal bone, accounting for about 2 % of all fractures, often derived from high-energy trauma in
young patients.
• The ideal treatment for displaced intraarticular calcaneal fractures remains controversial.
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• Open reduction internal fixation is the most popular surgical approach.
• A lateral approach is used to expose fragments, obtain reduction, and stabilize by plating with additional bone grafting .
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• Soft tissue complication is a major concern due to thin and vulnerable skin over lateral calcaneal wall which is cut and retracted during surgery and jeopardized by underneath plate.
• Rate of complications is between 15 to 25 %.
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Authors started the application of Kyphon (Medtronic) tools, in association with minimally-invasive techniques,
for closed reduction of Sander’s type II and III fractures and
balloon-assisted augmentation with both acrylic cement and calcium phosphate
(minimally- invasive percutaneous calcaneoplasty).
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SANDER’S CLASSIFICATION
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ESSEX LOPRESTI CLASSIFICATION
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OBJECTIVES
(1) To minimize surgical trauma by reducing complications,
(2) To standardize the technique, (3) Avoid immobilization by encouraging early
function (4) Allow partial to full weight-bearing in 4–6
weeks.
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MATERIALS AND METHODS
Retrospective study was done with 11 patients, 7 female and 4 male with a mean age of 58.4 years (from 28 to 81 yrs) who sustained displaced intraarticular calcaneal
fractures and were treated with minimally-invasive percutaneous calcaneoplasty
from January 2008 to June 2010 .
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• Preoperatively, conventional X-rays and CT scan with 2D and 3D reconstructions were obtained in all cases.
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Lateral preoperative radiograph of a Sanders type III fracture
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Preoperative CT scan reconstruction showing vertical displacement of joint surface
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• Out of 11 , 6 fractures were classified as Sanders type II and 5 as type III.
• 7 cases had a fall from height on hard ground and remaining had motor vehicle accidents.
• Conventional X-rays were performed postoperatively and at 6–8 weeks.
• Then with a CT scan at 1 year when full weight-bearing is allowed and at the last follow-up.
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Postoperative lateral radiograph showing reconstruction
and restoration
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• The American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot score was used for clinical evaluation.
• Graded as Excellent (90), Good (80), Fair (70) and poor (<70)
• Bohler’s angle was calculated to assess bone reduction.
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Bohler’s Angle
The angle is normally between 20 and 40 degrees; a decrease in this angle indicates that the weight-bearing posterior facet of the calcaneus has collapsed, thereby shifting body weight anteriorly.
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ANGLE OF GISSANE
The normal angle is between 95 and 105 degrees; an increase in this angle indicates collapse of the posterior facet
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Operative Technique• A 2-cm incision is made on the lateral-posterior
calcaneal wall and sinus tarsi is approached by visualizing depressed articular surface.
• Usually a smooth periosteum elevator is used
under image intensifier control to lift and relocate the articular process.
• Temporarily stabilization was done with K-wires.
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• Varus malalignment can be managed by single manipulation or with help of Steinman pin insertion in the tuber perpendicular to longitudinal axis of the calcaneum.
• Then a cannula is placed into the body followed by insertion of a bone tamp attached to a digital manometer (Kyphon, Medtronic, Minneapolis, MN, USA).
• The balloon is inflated gradually under fluoroscopy.
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• Now bone cement is prepared immediately prior to its injection into the defect and the balloon is removed.
• No cast is applied.
• Patients encouraged to actively bend the ankle with assisted weight-bearing and discharge in 2–3 days.
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Reduction of subtalar joint with periosteum elevator under
image intensifier control
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Intraoperative view demonstrating position of the balloon
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RESULTS• All cases progressed to bony union in 2–3
months.• According to AOFAS score, clinical results were
excellent in 6 cases, good in 4 and fair in 1.• Considering a normal Bohler’s angle between
20 and 40, • the mean preoperative value was 9.91 • while the mean postoperative was 22.97
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• Patients returned to work between 10 and 12 weeks.
• No wound complications or adverse reactions were observed.
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DISCUSSION
• Calcaneal morphology and height are essential for hindfoot and ankle function and fracture reduction.
• Recreating a congruent subtalar joint is mandatory.
• ORIF via extended lateral L-type retro-malleolar approach and plate fixation, is still most popular method, reporting good to excellent results in 60–85 % cases.
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• Treat displaced but reconstructable articular calcaneus fractures by minimally invasive percutaneous lateral approach,
• Obtaining reduction by manipulating fragments under fluoroscopy,
• and finally stabilizing the subtalar surface by injecting cement or a more biologic but resistant material (calcium phosphate).
• Literature about this new minimally-invasive technique is very poor.
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CONCLUSION
• Minimally-invasive percutaneous calcaneoplasty can represent an alternative to open reduction internal fixation
• in the treatment of calcaneal fractures, • allowing stable reduction without plating, • early function recovery and • short hospital stay.
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THANK YOU