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Malunited Calcaneal Fractures

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Malunited Calcaneal Fractures CALANEAL MALUNIONS DOLFI HERSCOVICI , JR TAMPA GENERAL HOSPITAL TAMPA, FLORIDA Disclosure Information: The author does not have any financial interests or relationships with any of the products discussed during this presentation. All products discussed during this presentation have been approved for human use by the FDA. WHY SHOULD WE FIX CALCANEAL FRACTURES? Because we can We have eqqpuipment we need to use Saw it done once, thought IlddiI could do it Pays well and you need the money Trying to decrease potential future complicat ions ANATOMY OF A FRACTURE Force dri ves the lateral process of the talus into lateral wall of calcaneus Extends medially to sustentaculum anddilllfd medial wall, fracture line runs superolateral to inferomedial Force then exits anteriorly near anterior column or calcaneocuboid joint Secondary fracture line results from continued impaction of the talus into the calcaneus Begins at apex of angle of Gissane and exists superior just posterior to post facet or inferior to tuberosityygg creating tongueue--ttype pattern ANATOMY OF A MALUNION Tuberosity fragment translates laterally and superiorly Decreases height Alters lever arm effect of calcaneus Flattens talar inclination and talocalcaneal angle Fibula impingement Increases width Results in lateral exostosis >2mm of disppplacement of post facet Changes loadload--bearingbearing characteristics Direct cause of subtalar arthrosis WHAT HAPPENS IF WE DON’T FIX THEM? Neurologic Problems Entrapment of the posterior tibial and suralll nerves Cause: Significant ddspaceisplaceme nt to of medial and lateral fragments WHAT HAPPENS IF WE DON’T FIX THEM? Tendon Problems Impingement, dislocation or entrapment of peroneal tendons Cause: Displacement of lateral wall entraps or dislocates tendon at fibu la or anter ior to fibula WHAT HAPPENS IF WE DON’T FIX THEM? Bone Problems Painful exostoses can produce difficulty with shoe wear Widened heel Loss of height Hindf oot varus or va lgus Cause: Malalignment of the hindfoot alters pattern ofhf shoeoe--wearwear andid gait WHAT HAPPENS IF WE DON’T FIX THEM? Joint Problems Painful arthritis of the subtalar and calcaneocu bidjitboid joints Lateral ankle joint pain with talar tilt CalcaneoCalcaneo--fibularfibular impingement Cause: Malunion of the 4 joints WHAT HAPPENS IF WE DON’T FIX THEM? Joint Problems Impingement of the ankle joint Anterior Impingement secondary to loss of talar height and inclination Results in decrease in ankle dorsiflexion Cause: Malunion of the 4 joints RADIOGRAPHIC EVAATOALUATION Plain Radiographs Lateral, Broden, Harris views Saltzman View Saltzman, el-el-Khoury,Khoury, Foot Ankle Int, 1995 Normal Pathologic RADIOGRAPHIC EVALUATION CT Scan Most reliable tool to evalliluate malunions 22--DD with sagittal and coronal cuts Sagittal 33--DD helpful for prepre-- operative planning, especially if osteotomy is planned Coronal CLASSIFICATIONS Stephens and Sanders Type I Lateral exostosis with or without lateral arthrosis of subtalar joint Type II Type I + arthrosis of entire jjj oint Type III Type II + malunion of the calcaneal body Stephens & Sanders, Foot Ankle, 1996 CLASSIFICATIONS Stephens and Sanders Problem with this clifiiidlassification is doesn ’t address: Loss of talar height Loss of talar inclination (normal 21 d)degrees ) Indications for a distraction arthrodesis CLASSIFICATIONS Zwipp and Rammelt Type 1: Incongruence of the joint Type 2: 1 + Hindfoot varus/valgus Type 3: 2 + Loss of hihheight Type 4: 3 + Translation Type 5: 4 + Talar tilt Zwipp & Rammelt, Zbl Chir, 2003 TREATMENT Conservative Care This has NO Role Patients have already failed conservative care Goal of Surgical Treatment Improve the alignment of thhidfhe hindfoot Decrease bony pr omin ences Decrease pain TREATMENT Soft Tissue Bony Procedures Procedures Exostectomies Repair of Peroneal InIn--situsitu fusion tendon subluxation, Distraction dislocation, or arthrod esi s stenosis Reconstructive osteotomies Lengthen Achilles tendon Combinations SlNSural Neurectomy TREATMENT Soft Tissue Reconstruction To obtain hindfoot height Must lengthen Achilles tendon Hoke 33--cutcut Release Strayer TREATMENT Soft Tissue Reconstruction Repair the peroneal tendon pathology Often corrects with lateral wall exostectomy Detach Peroneal retinaculum as periosteal sleeve from fibula and staple or anchor to posterior fibula surface TREATMENT Bony Reconstruction DO NOT NEED A PERFECT REDUCTION Improve the alignment of the hindfoot +/+/--OsteotomiesOsteotomies Decrease bony prominences May need a fusion TREATMENT Osteotomies/Exostectomies Fibular Osteotomy Resection of the tip of the fibula Does not address pathology of calcaneus Ibister, JBJS, 1974 Fibular Resection Lateral Wall Exostectomy Decreases lateral impingement MlMay also remove t hfhe far lateral joint if arthrosis is present Lateral Wall Exostectomy TREATMENT Osteotomies/Exostectomies Varus/Valgus Osteotomy Corrects malalignment of the hindfoot Doesn’t address arthrosis Sliding Corrective Osteotomy Does not improve talar declination DddiDoes not address anterior ankle impingement Huang et al, Foot Ankle Int, 1999 TREATMENT Fusions InIn--SituSitu Fusion Good results regardless of talar height or talar inclination if anterior ipiimpingemen tibt is absen t Need to have greater than 10 degrees of ankle driflindorsiflexion Chandler et al, Foot Ankle Int, 1999 TREATMENT Combinations: Fusions/Osteotomies Romash Osteotomy Osteotomy through primary fracture line Restores bony anatomy Romash, Foot Ankle, 1988 Dis trac tion A rth rod esi s Improves talar inclination Restores hindfoot height Can correct malalignment of hindfoot without osteotomy Carr et al, Foot Ankle,1988 TREATMENT Author’ s Preferred Treatment Clinical Exam No Peroneal tendon dislocation Dorsiflexion >10 degrees Radiographic Exam Bohler’s angle >15 degrees No arthritis of subtalar joint TREATMENT: Exostectomy lateral wall TREATMENT Author’s Preferred Treatment Clinical Exam No Peroneal tendon dislocation Dorsiflexion <10 degrees Radiographic Exam Bohler’s angle <15 degrees AhiiArthritis su blbtalar jijoint No varus/valgus malalignment of calcaneus TREATMENT: Strayer, Exostectomy, Distraction arthrodesis TREATMENT Author’s Preferred Treatment Clinical Exam Peroneal tendon dislocation Dorsiflexion <10 degrees RdiRadiograp hiEhic Exam Bohler’s angle <15 degrees Arthritis subtalar joint varus/valgggus malalignment of calcaneus TREATMENT: Strayer, Exostectomy, Distraction arthrodesis, Osteotomy of Calcaneus, Repair dislocation tendon, Sural Neurectomy BONE LOSS Marine, Afghanistan, IED, open calcaneus with bone loss BONE LOSS Positive for Infection BONE LOSS BONE LOSS Femoral Head + RIA BONE LOSS CONCLUSIONS Malunions Decreases height Alters lever arm effect of calcaneus Flattens talar inclination and talocalcaneal angle Fibu la imp ingement Increases width Results in lateral exostosis Varus/valgus malalignment CONCLUSIONS Goal of Surgical Treatment Improve the alignment of the hindfoot Decrease bony prominences Decrease pain DO NOT NEED A PERFECT REDUCTION CONCLUSIONS PrePre--ooppgerative Planning Good Clinical Exam Adequate X-X-raysrays and CT scans CONCLUSIONS Treatment Soft Tissue reconstructions Bony reconstructions THANK YOU.
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