Benjamin Overley, Jr, DPM looks at the surgical objectives of calcaneal fracture repair. Dr Overley reviews the techniques and goals of repair through radiographic images and provide pearls of wisdom for avoiding complications.
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Benjamin Overley, Jr, DPM
Surgical Skills Committee
Section Editor for Trauma-Journal of Foot and Ankle Surgery
Foot and Ankle Specialist/PMSI Orthopedics
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Male Speaker: Okay guys. So, I’m pinch-hitting in this time slot, I was going to do this and talk later today but I still have one more talk later, I think it’s Jones fracture for you guys to suffer through. Calcaneal fracture, this is really a broad term. I didn’t really want to define this, we can be here for two days with me going over classifications systems and all these different things and uniqueness of the different fracture patterns and how your treat them, but I think probably you’re going to get, as residents, you’re going to get more out of actually seeing surgical ways to approach these things and giving you some tips and techniques and what do we do with these perimeter fractures and patients that don’t fit the mold, they maybe have a poor soft-tissue envelope, diabetic, questionable PAD. And remember in a lot of these cases too there also injuries that occurs to the vasculature that feeds the calcaneus. If we sort of approach this sort of willy-nilly and we don’t really think about what we’re doing, we can end up with non-unions and I’ve had that happen myself. If you’re not getting complications in your surgeries you’re probably not operating enough. So for my perspective this talk is really going to be gauged directively really towards surgical management of these types of injury patterns. There’s my disclosures, and I’m a paid speaker for this company’s learning objectives, it’s up there, I’m not going to read and you guys can all read the slide, but I think the take-home thing is just understanding that each one of these things are very unique in of themselves. You can’t lump calcaneal fractures together, there’s more classification systems you can shake a stick at. So it really doesn’t give us a lot of information on really what we’re supposed to do with these patients when see him. And it makes it really difficult fracture to treat. Calcaneal fractures, there’s really no winners in cal fractures, or really even for that matter pylons, they’re both typically related to vertical compression with an applied shear rotation or twist and that’s what defines the fracture pattern. But at the end of the day none of them do really good, it’s just a grease of loosing. If you can get these patients back as close to an atomically position, I mean clearly that’s what we want to do, but some instances where you just can’t do that as a result of soft tissue envelope, et cetera. So why do we have so much trouble with these fractures? Well, if you take a look, I mean you can see there’s a lot going on in that CT scan slide, of that imagery. And when you take a look at all the various different fracture lines and fracture patterns and we have fallen fragments, we have pieces of bone falling in the fracture fragment or fracture lines in which it’s rotated, it’s in the heel, the tuber, the calcaneus is in varus. There’s a depression of the joint, especially the posterior facet, loss of calcaneal height. All these things come into play. And it’s not an easy thing to get these things back together even in the best setting with good sort tissue. And you can see a fracture pattern like that where we’ve got intraarticular extension in two points, so the CC joint as well as the subtalar joint. And then in addition we got to crank this thing out and we’re definitely going to have bone loss when we get that back and how do we address that. Again, what we’re trying to do is get from this, which is one of my preopt CT scans in the same patient postoperatively. So if we can get from your right to your left, great, if we can we have to have some other ways to go about this. So wound issue, this is really the hot button topic with calcaneal fractures is wound issues. When is the skin good enough to actually make a move on these things? And I would caution all of you, especially you residents, you’re chopping it a bit to get into the OR with these things. But one thing you need to realize is you do have time, and you don’t have forever but I think the tendency in what I’ve seen over the years with young practitioners, guys just had a fellowship, just had a residency and my fellowship is wrapping this year, in fact my fellow is joining Dr. Showenhouse [phonetic] and Dr. Troiano [phonetic] in Philadelphia and going to be working with those two individuals, so God bless their soul. I’m sorry Harold, I got you to first talk without taking any shots I can’t go through too. [Laughs] And Harold is a great man and we have a great relationship and I appreciate him having me out here, I didn’t mention that either the first time around. What we’re talking about here is when do we pull the trigger on these, when do we jump in, when do we make that decision. And it’s again so unique and it’s relative to the type of fracture pattern that you’re dealing with, the individual that you’re dealing with, their age.
These things are typically blown out, the soft tissue is very dowie, and it can also be deceptive, you can look at and say, “Well it doesn’t seem like it’s that bad, I can probably make a move on this right away.” And then you get that first postops splint dressing, and you take that off and you do one of these with your eyes, and before you know it you’re staring at your hardware in three or four weeks. So we don’t want that to happen. So what I would say to you is, you have time with these pylons or these cal fractures, any of these bad blowout fractures where there’s a lot of swelling, a lot of blood. We know that if you see a clear blister it’s probably just related to exudative edema, but if you see hemorrhagic blisters. That’s coming from the bone, that’s where that’s coming from. And guess what? If you cut through that you’re going to be looking at bone because that’s the origin of where that blood is coming from. Subtalar joint arthritis, they all get it, it’s just what degree do they get it? It’s no different than a really bad trimalleolar or pylon fracture. You’re going to get arthritis. There’s no way around. I have patients in sort of in orbit, from ORIF [phonetic] calcaneal that I did two, three years ago. And every two, three months they come in and I hit them up with some steroid in their subtalar joint and they’re good for a little bit. But, just like anything else, the steroid shots, sort of low diminishing returns, you get the most really from the first one, and then it gets down to the point where they’re trying, “How long did it help you?” “Maybe two weeks.” And that’s reality, because once you start to get that, and I don’t care how well you get this inline. Justin Fleming is a great surgeon and a very close friend of mine. He will spend 14 hours trying to put these jigsaw puzzles back together, and at the end of the day his x-rays look great, his videos look great and I wish I had his presentation to give. But the reality is they’re all going to get arthritis. As long as you lay the crate, you let your patients know that this is what’s coming down the road, there’s nothing I can do about it, the genie is out of the bottle or however you want to put it. And let them know that this isn’t the last time we’re going on and working in and around this heel, then I think you have a well-informed patient and two, they begin to get more realistic sort of expectations instead of, “Oh we’re going to put you back perfectly,” that’s not going to happen. You’re going to get as close as you can get, then you’re going to deal with it, the after effects. So these are patients you are going to take into matrimony with you. I have several of them. I’ve been married several times over. It seems like every week. I get these patients with really, really complicated deformity, fractures, et cetera. These are patients that continue to see you but they also help to build your practice with their own referral. Knowing that this stuff is coming is just part of the game. And then also that you can have sort of this longstanding hindfoot deformity, it happens. Even if you get them back perfectly there’s always a settling effect, it’s like a house settling, the bone is very soft. Calcaneus is just like an egg, sort in the inside, hard in the outside. And when they do settle, even with hardware in there, they’re sort of shifting, fragments and everything does solidify over time, it is a bone that if you give it the opportunity it will heal, but at the end of the day you’re still going to be dealing with these hindfoot deformities that you will have to comeback and correct. You can’t just let them go. My ex-partner, his brother is a very famous foot and ankle surgeon out of Georgetown did, and this is before I actually joined the practice. But looking at this x-ray, there’s a lot of things going on here and from my radiographic eye, I look at this and see, well I see the subtalar joint really arthritic but I really can’t see the subtalar joint, so that leads me to believe, maybe the height wasn’t restored, and you can see it sort of buckled up in the end. And the thing that I always look for, and a good reference point for you residents, is always look for the talar dome, and wherever the talar dome is kind of gives you, a line right out of that talar dome or right out of the center of that talus. It’s half a dome actually out the back of the ankle, what does that tell you? Well it tells you that the calcaneal height was never restored because if it was truly brought back up the talus would go with it and it would rotate back into the ankle joint, well in this case you can see it did not. And this is uniforately an individual that you can also see the arterial supply on the back side. And this is somebody that needs an ankle replacement, he’s already got this subtalar joint effusion but he does not have the vascularity to support either, so he gets a brace and that’s what he’s going to go away with. This is where the rubber meets the road with calcaneal fracture, open reduction, internal fixation. You got to get them out of OR as best as you can. If it’s really, really fragmented sometimes you cannot get them out of OR, you can try, though you may, you literally will leave them with a little bit of error [phonetic], and it’s really tough to look at in the operating room even when you’re flipping x-rays around and having c-arm available, and looking after heal, from a clinical perspective, you still are never really sure.
And you won’t find that out until down the line, until you start getting your postop x-rays and CAT scans, how good of a job you really did. So these are really the take home points as residencies would be the things that are going to be asked of you in exams, questions other docs are going to ask you. These are the things that you need to do know, and these are really the preponderance of all calcaneal fractures, which is we want to height back, we want get in clinician, we want it out of ORIF [phonetic], double density fracture, which I’ll show some x-rays of it later, we want to get them pulled back out to length. If you can get these things back out to length, the potential is that they’ll do okay to good. And none of them are ever going to do great and I can’t stress that enough. So conventional approaches with hand’s off, using Kirschner wire fixation and bending them. This becomes, you know, you’re creating this entire sort of myofascial leguminous flap, and what I try not to do in my calcaneal fracture surgeries, is you don’t want to skeletonize bone, and that goes really osteotomies or fusions or anything else. You start stripping away all that blood, that extraosseous blood supply and then your fusions don’t heal or your fractures don’t heal, well it’s no wonder. Try to keep this stuff limited, believe me they’ve already done enough periosteal dissection in these cases with the fracture itself, so try not to add to the misery by really, really stripping things away. Get things to the point where you’re evacuating tissue that’s not supposed to be residing in bone out of it, and then work from there. And this is a typical incision that you do for this and I don’t do this, sort of lazy curve, I like to make them sharp and then do that apical stitch, right at the end of the cracks or the bend of the incision. The first thing we want to do is we want to get heel out of ORIF, and how we do that, well once we located the primary fracture line, we want to sneak in through that fracture defect and we want to sneak, you want to reach all the way across the calcaneus and we want to get that [indecipherable] [12:04] on the medial side to drop and pop back into place. And what will typically happen is, that if you can do that initially, the posterior faced will then maintain its reduction or it’s a lot easier to hold it up, and if you can’t get it, the only way you’re going to get it is getting through the fracture line. You can’t really access that through the subtalar joint no matter how depressed or blown out it is. So you really do need to use your fracture defect almost to your advantage and really get in there and get that [Indiscernible] [12:38] reduced. Typically once you reduce it, and you can do that with the axial view in the operating room, it will hold and stay in place. And then in addition, then you can move towards the rest of your reduction. And you can see that’s what I’m doing here. I’ve already gotten my temporary k wires holding my fixation, this is a case where there’s a lot of lateral wall combination. Some of that will go away, with lacked plating we can apply these place that fit and they’re snug and they hold and they’re very stable. But understand that when you’re putting all these different pieces back together you’re going to actually size in pieces because they’re not viable. What you can see I’m starting to regain the height and I’m beginning to hold that posterior for setup, and you can see that with that one wire coming superior inferior and almost mimicking the path of the posterior facet. And that’s what you want to do. You want to get right underneath it and crank it up and lever it up and then hold it up with some sort of raft or pins or support pieces. And then after it’s just simply played application and trying to keep your screws out of fracture lines. So you can see that’s what it looks like and it’s intact, sometimes that’s as good as you’re going to get. It gets reduced, and what you will typically see as well is if you look at the very back of that heel, you will also see there’s non-weight bearing projection, this is what you got but if you look at the back of the heel you almost see a vacancy extending out of the back of the calcaneus. Well that tells me that I actually got my reduction, because if you truly do a good pylon or calcaneal reduction, you should have a little defect, because the thing that actually or the fracture when admitted actually compresses and sort of dives down bone within bone. So, to really know if you got a good reduction, you really need to lift that back up again. If you can’t do this and you can’t get in and you can’t really go after these things the way you like to, what do you do? So here’s a good illustrative case, and this is an individual and you can tell she’s very thin by the shape of her ankle there. You can also tell those white things are not tattoos that are running down. So this is an individual that we got anterior and posterior circulations supply issues.
And in addition she’s diabetic and she pretty overweight with a cal fracture. I know I’ve got to fix this so what do we going to do? You can do this type of a technique and you can see her, the slender ankle, and you can almost guarantee if you go into this individual that you’re going to have soft tissue complications. So what I typically do is I’ll do this with external fixation and I’m just going to start with the transfixation pit in the tail or neck. And you can see setting up double pins, one to the calcaneus, one through the talus and you can see what it looks like. And now I can take my construct, which is just very simple, the same construct used for subtalar joint effusion essentially. And what I’m going to do is I’m actually going to rotate and move that around. And I can do all these different things, I can add in different pins to different pieces of the fracture and I can sort of move the fracture where I wanted to go. And just thinking, one little apparatus, and it doesn’t matter really what you use just as long as you have the ability to manipulate these fragments without going in. So you take a look at that, that’s all the different directions I can move this foot in this calcaneus, that’s a lot of different places I can go with this. You tighten it down and you can see what it looks like. So there’s postop, and you can see the nice little talar hole with the talar pin, it wasn’t a calcaneal pin, with the calcaneus healed, this is not a case where I had to go in and actually open this patient, this is all done percutaneously. In fact if you’re taking a look at a lot of literature coming out of Europe and we sometimes lag behind them not only in our products that are available to us but also in our techniques. Over there there’s a very strong push or movement not to even fix these at all. Cast them, and then comeback and then do all the repair, osteo [phonetic] effusions and all that stuff. Have it done in one surgery and just leave it where it is. This is sort of along those lines but it’s not as aggressive as going in and plating, but it is something you can do in addition, and here’s another type of technique, you can see calcaneal fracture here. And we got that buckle rolled back that we typically see with the calcaneus where the top of the posterior tube wants to touch the back of the talus. So we need to get that out, and how do we do that? Well we got to distract the subtalar joint, we have to open up that joint, and we can do that by putting pins up in the tibial segment and pushing down, so that’s perfect indication for this type of technique. This is woman that had PAD and unfortunately you can’t see that little arrow there, what it says, but these are just after screws that’s all they are. And all I’m doing is just placing these in here, and that they’re going to be things that stay behind after I get that frame off. Very simplistic frame, once central pin and then two pin [phonetic], that’s all it took. And you can see what she looks like down the line, that one screw you can see is beginning to migrate out, that eventually did come out, but that’s what she looks like 12 weeks postop. And I practice in areas, as Harold said, outside of Philadelphia. Harold is an urban, he gets panicky if he gets away from too much storage of Glenlivet or his tailor-made golf club. I’m out in the farm land, so I’m out in the sticks, it sort of like, on the one town between the two towns, it means something. So we have a lot of people out there that liked to do a lot of motocross and quad riding and things like that. So here’s a perfect example of “hold my beer, watch this.” A 45-year-old guy and his son who’s of course made of rubber and was doing these tremendous jobs, while 45-year-old days, “well I can do that too.” Hang to this, and even with motorcycle boots on this is what he ended up with. It was a case where we had a lot of swelling, so it ends up, the double density fracture is calcaneus, posterior facet is fragmented. It looked like rice granules. So just went in and remove all of that, simple construct and you can see there’s fully traded screws, really trying to secure the lateral wall, you don’t want to put these immediately and that’s another technique, and the reason for that is if you do put them immediately and you do actually engage the medial distal portion of the calcaneus you can actually pull that, heal back in the varus. So you want to aim these more along the lateral course. I do all these prone, I like to take the Achilles out of it, so I do them prone and I’ll actually flex their knee, they end up on a knee role, and their leg sort of just hanging like that.
And by taking the Achilles out of it, you can really manipulate them and get them back out to length, and it makes it so much easier to work, and you’re not fighting with yourself in doing this the entire time trying to sort of aim your stuff. You can stand there comfortably and sort of get exactly where you’re going with it. So this is what he looks like down the line, and I’m sure he’s gone on subtalar joint effusion at this point, at least if what I did worked, because when you’re going in there and you’re moving that much fragmentation, there’s really not going to be a whole lot left, but you can see what he looks like from the healed calcaneus standpoint. And he actually did quite well but it falls under the heading of just because they go away doesn’t mean they got better, but last time I saw him he was doing good. You create a stable arthrosis [phonetic] and that’s an area by removing that fragmented posterior facet. So really we’re down pretty much the end of this talk. The thing again that I would stress to all of you, especially the residents is these are not easy cases, and again they don’t ever work out perfectly. These patients are never going to be without pain, they are always going to have some disability, and they will require further surgery. You never want to tell this individual or this patient on the perspectives of “Hey Mr. Jones or Mrs. Jones, we’re going to put you back and it’s going to be perfect.” This is not a lateral malleolus fracture, and you can see it’s not something that you can line up and palpate along with your thumb and go, “Man that’s really perfect and it’s anatomic.” It’s not, that’s not reality with this type of fracture pattern, it just doesn’t happen that way because there’s so many pieces, there’s so much going on, it’s a busy fracture. And there’s a lot of components to it that you have to grasp before you take these things on and you begin to do them. And a lot of you maybe coming out, I don’t know how many of you are finishing up your residency here on the next month or two, and maybe you’re not going under fellowship, majority I’m sure still go out into practice right away, the trend was years ago, I was actually the second DPM to join an orthopedic group in the entire state of Pennsylvania. As that is taking place and that incorporation of a surgical nature. As that incorporation is taking place over time it is not uncommon for you as you get done with your training to join an orthopedic group, which means you’re going to become very up close and personal with these types of injuries, because I can tell you at the end of the day your orthopedic colleagues want nothing to do with them. You’re being brought in to do their foot and ankle surgery, that’s part of the foot, go get it champ. So you better get a really good grasp when you’re dealing with these complicated fractures. Metatarsal fractures, Harold always told me, if two ends of a metatarsal in the same zip code they’ll heal. And I believe that to an extend, and this is not dealing met fractures, it’s not dealing with isolated very singular ankle fracture, this is dealing with really, really complicated trauma, anatomy, you need to understand it all and understand that the these patients are not going to do great and they’re going to need further surgery. As long as you fallow those tenants that I showed you, about getting the height back, heal out the varus, all these things, restoring length, these are all tenants of fracture treatment. And you have to adhere to them. And they’re there for a reason. There’s a reason why we can’t always boil down everything into those four things. Your dissection, your fixation, when you get them walking, all of these things. It all comes down back to those four tenants of AO fixation. Even when you see me doing a frame case and I’m perking screws, I’m doing it for reason, I’m not advocating that that’s what you do with the 25-year-old guys who’s got really good tissue. Remember that a lot of these cases are people either trying to avoid death, avoid death by fire, death by incarceration or just incarceration in general or a very jealous husband, I’m not joking about that, I had bilaterals when I was down in the Philadelphia area. Somebody showed up when they weren’t supposed to, and somebody had to make a quick exit out of the balcony. This stuff does happen, so that always makes things very complicated when you’re dealing with two, they’re bad enough when it’s one. So, take your time with these, you do have time, don’t get carried away, don’t go crazy, unless you’re seeing literally within an hour and just that day they happen to be NPO. It’s kind of like baby pigeons are out there but I’ve never seen one. So I would assume that they woke up in the morning, they probably had something to eat or drink. So, your changes are, by the time you’re laying them down, putting them on ice and then contemplating actually going in and fixing them, now you reach that hour of time where you probably should touch it.
Let the tissue calm down, another technique but I don’t have on here is if you do run into fracture blisters, Paul Turneta [phonetic] who works out of Mass General in Harvard has advocated using wound vac on a fracture blisters. And I started doing that probably about a year and half ago because I see a lot of pylons and a lot of cal fractures. And it does really works, you just land some, throw back on it, it really reduces that time to OR because it can really get the soft tissue under control a lot faster than slathering with Elmer’s and slapping Adaptics on and stuff like that, because then it’s just a waiting game. So, that’s all I got and like I said I’ll be back this afternoon to go over more of my traumatic woes with Jones fractures. I think I have three minutes Harold and I think we’re done. Thank you for your time.