Volume 05 / Issue 03 / September 2017
Page 44
boa.ac.uk
JTO Features
How I Do… Percutaneous Fixation of Depressed Intra-Articular Calcaneus Fractures Jamie A Nicholson Co-authors: LZ Yapp, Robert AE Clayton The management of Displaced Intra-Articular Calcaneal Fractures (DIACF) is controversial following the UK Heel trial1. This is partly because of the morbidity associated with the extensile-lateral approach. However, there is now increasing evidence that percutaneous techniques result in satisfactory patient outcomes with significantly reduced rates of wound complication and deep infection2,3,4. Numerous methods have been described from simple Steinmann pin reduction to complex procedures with arthroscopic assistance5,6. We have been using a percutaneous fixation method for over five years. Pre-operative CT scans are obtained in all cases. Surgery is usually performed within a week of injury except in rare cases of severe skin tenting.
Surgical technique
Jamie A Nicholson
The patient is placed in the lateral position with the foot raised. The image-intensifier is positioned at the end of the table, such that it can easily be rotated from a lateral to a Harris-axial view without moving the foot.
A guide wire is driven into the largest displaced articular fragment. This wire is used as a joystick to elevate the depressed fragment, restore height and reduce the posterior facet. Occasionally restoration of Bohler’s angle is assisted by inserting a periosteal elevator through a small incision below the depressed articular fragment in the sinus tarsi (Figure 1). The hindfoot varus is then reduced with two 6.5mm cannulated-screw guide wires being driven along the tuberosity towards the anterior process to restore heel valgus.
In tongue-type fractures guide wires for the 4.5mm partially threaded cannulated-screws are placed into the tuberosity. If there is no comminution of the body, the body acts as a fulcrum further around which to reduce the posterior facet (Figure 2). In joint-depression fractures the same wires can be passed latero-medially across the primary fracture-line into the constant, sustentaculum tali fragment to fix the posterior facet fracture (Figure 3). Final screw insertion is then undertaken. Two 6.5mm screws are inserted over the provisional wires into the anterior process of the calcaneus. It is essential that these are fully-threaded to >>
Figure 1: Reduction of the posterior facet ‘tongue type’ component