Management
Operative versus non operative
- RCT of 309 displaced intra-articular fractures
- operative v non operative management with 2 year follow up
- 2 year follow up
- overall no difference in outcomes
- better outcomes with operative: Type II / non workers comp / women / < 29 / anatomic reduction
Non Operative Management
Indications
Sander I - non displaced
Sanders IV
Diabetes / smoker / peripheral vascular disease
Compound fractures
Technique
POP
NWB 6/52
Complications
Subtalar OA
Calcaneocuboid arthritis
Hindfoot malunion
Peroneal impingement or subluxation
Posterior tibial nerve entrapment
Difficulty with show wear
Operative Management
Aims
Pain free functional foot that can fit in a shoe
Goals
1. Restore heel shape (height, length / width / valgus)
2. Reduce joint surface
Options
ORIF
Closed reduction / percutaneous pinning
Primary subtalar arthrodesis
ORIF
Technique
Position
- patient on side, blankets under foot
- operated foot up
- radiolucent table, image intensifier
Approach
- extensile lateral approach
- behind posterior edge of fibula
- along border of calcaneum
- distal incision along inferior margin calcaneum
- angle up towards CCJ
Superficial dissection
- elevate full thickness flap with peroneal tendons
- K wires to retract skin flap: 2 in talus / 1 in fibula
- expose CCJ
Reduction
- Steinmann pin into tuberosity through heel skin
- can elevate and pull out of varus
- open lateral wall fragment to access to subtalar joint
- if type 2C may need lateral wall osteotomy
- divide interosseous ligament
- homan / lamina spreader to expose STJ
ORIF
- reduce medial fragments and work laterally
- restore posterior facet with screws
- restore calcaneum height / Bohler's / varus by reducing tuberosity fragment
- reduce posterior facet & lateral joint fragment onto sustentaculum fragment
- elevate anterior process fragment
- locking contoured plate
Closed reduction and percutaneous pinning
Technique
Reduction
Steinmann pins
K wires
Results
- 287 displaced intra-articular fractures
- MUA / Gissane spike percutanous reduction / K wire fixation
- 72% good or excellent results
- 1.7% deep infection, 7% superficial infection
Primary Subtalar Arthrodesis
Indications
Type III / IV Sanders
Complications
Wound necrosis
Sural nerve neuroma
Compartment Syndrome
RSD
Non union
Heel pad problems
Infection
Deep infection
- Debridement and removal of metalwork
- Free flap over Abx beads, IV ABx
- Late grafting and STJ OA
- RCT of 309 displaced intra-articular fractures
- operative v non operative management with 2 year follow up
- 5% deep infection
- 17% superficial infection
Osteoarthritis
- RCT of 309 displaced intra-articular fractures
- operative v non operative management with 2 year follow up
- STJ arthrodesis: non operative 17%, operative 3%
Calcaneal Malunion
Issues
Varus hindfoot locks Midfoot
Peroneal impingement
Shoewear problems
Options
Lateral wall exostectomy and peroneal tenolysis
+/- STJ arthrodesis
+/- calcaneal osteotomy