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Minimally invasive plate internal fixation for calcaneal fractures
Chinese Journal of Traumatology 2010; 13(5):313-315
. 313 .
Minimally invasive plate internal fixation for calcaneal fractures SHAN Shu-lan 单淑兰, XU Jun-ling 许峻岭*, YAO Shu-zhang 姚书章, YU Guo-sheng 于国胜 and LIU Yu-qin 刘玉琴
【Abstract】Objective: To assess the clinical efficacy of minimally invasive plate internal fixation for the treatment of calcaneal fractures. Methods: Manual reduction, rectification of deformity, and cold compress with traditional Chinese medicine were used preoperatively to relieve swelling and pain. A small incision was made to expose the articular facet and to perform anatomic reduction and plate fixation. Self-made traditional Chinese pharmaceutics were applied postoperatively on the surface of the wound to accelerate bony union.
Results: All the 40 patients were followed up for at least 1 year postoperatively. According to the Maryland scoring system, the excellent and good rate was 87.5%. Conclusion: Minimally invasive plate internal fixation has the advantages of relatively mild injury, reliable fixation, good recovery, and rare complications in the treatment of intraarticular fractures. Key words: Surgical procedures, operative; Fracture fixtion, internal; Calcaneus; Manipulation, orthopedic Chin J Traumatol 2010; 13(5):313-315
C
alcaneal fracture accounts for 60% of all foot fractures and most of them (70%) are intraarticular fractures.1 Owing to the application of C-arm fluoroscopy during operation and internal fixation technique, substantial progress has been achieved in the treatment of calcaneal fractures. From January 2004 to January 2009, 42 intraarticualr calcaneal fractures in 40 cases were treated by minimally invasive plate internal fixation and the result has been proved satisfactory.
Preoperative management Emergency operation was performed within 24 hours after injury providing the general and local conditions allowed. If soft tissue swelling was obvious, the widening on the horizontal axis and shortening on the longitudinal axis of the calcaneus were manually corrected to restore Bohler and Gissane angles under general anesthesia. After manipulation, the affected limb was elevated and the wounded foot was given cold compress with gauzes immerged in self-made traditional Chinese pharmaceutics and freezed before use.
METHODS & RESULTS Demographics and fracture types There were 40 cases involving 42 calcaneal fractures, including 27 men and 13 women with the age ranging from 20-46 years and mean 35 years. According to Sanders classification,2 17 cases belonged to type II fractures, 23 type III fractures and 2 type IV fractures. The cause of injury consisted of fall injury in 22 cases, traffic accident in 15, and crush injury in 3.
DOI: 10.3760/cma.j.issn.1008-1275.2010.05.012 Department of Orthopedics, Cangzhou Intergrated Traditional and W estern Medicine Hospital, Cangzhou 061000, Hebei Province, China (Shan SL, Xu JL, Yao SZ, Yu GS, and Liu YQ) *Corresponding author: Tel: 86-13932720555, E-mail: [email protected]
Surgical indication All types II and III and some type IV calcaneal fractures as well as over 3 mm displacement of the articular facet could be treated by this method. Surgical procedures Patients with unilateral fracture were placed in lateral decubitus position and those with bilateral fractures were positioned prone. A 5-cm long incision was made parallelly with the subtalar joint or footplate with the midpoint located at 2 cm below the external malleolus to expose the bone. Care was taken not to damage the sural nerve. The long and short tendons of fibula were pulled out to the inferior part of the incision and thus the fracture site was revealed. The calcaneofibular ligament was cut off to expose the subtalar joint and lateral wall of the calcaneus. Schanz pin was used to
. 314 .
pass across the calcaneal tubercle for skeletal traction so as to correct the length and width of the calcaneus. Subsequently the traction orientation was adjusted inclined to the medial or lateral side based on the introversion or extroversion status of the calcaneal axis to rectify angulation deformity. A small periosteal detacher was inserted into the fracture interspace at the posterolateral wall to pry the lateral wall of the calcaneus and uncover the posterolateral articular fecet. The depressed posterior articular facet was reposited by leverage using a round osseous pin or an elevator. The reposited lateral articular facet was bound to the medial side using a 2 mm Kirschner wire to secure an anatomic reduction. Every bone fragment of the calcaneus from the calcaneal tubercle to the cuboid joint was transfixed. Under C-arm fluoroscopy, the position of the fractured bone and the length of screws were examined (Figures 1 and 2).
Chinese Journal of Traumatology 2010; 13(5):313-315
are homologous bone (Aorui Co, Shanxi, China) and artificial calcium phosphate bone (Ruibang Co, Shanghai, China). The fractured bone was fixed with 56 pore butterfly-type plates and thread screws. Screws at the anteriosupra plate were placed towards the direction of the sustentaculum tali and meanwhile bone fragments located at lateral calcaneus were fixed; screws at the anterioinferior position were fixed to the anterior part of the calcaneus and bone fragments involving in calcaneocuboid joint; screws at posterosuperior area for fixation of calcaneal trochanter; screws at middle part for fixation of the sustentaculum tali in an attempt to offer a reliable and firm hold. After recheck and confirmation of a satisfactory reduction by fluoroscopy, the drainage tube was left in situ and incision closed. Postoperative management Patients were given pressure dressing and wounded limbs were elevated postoperatively. Aescin or manicol was used if necessary. Self-made traditional Chinese pharmaceutics I consisting mainly of Carthamus tinctorius, Terrapin, etc and II consisting mainly of Himalayan teasel root, Myrrha, etc were taken orally. Nonweight-bearing functional exercise began the second day after operation. X-ray photographs were taken 8-12 weeks after operation. Once the fracture line disappeared on radiographs patients were allowed to weight-bearing ambulation with crutches.
Figure 1. The length of incision.
All the patients were followed up for 1-5 years. According to the Maryland scoring system, excellent results were achieved in 12 cases, good in 23 , fair in 4, and poor in 1, with the excellent and good rates of 87.5%. Necrosis or stripping of the epidermis was not found in any cases.
DISCUSSION
Figure 2. Fracture fixation is implemented.
Bone graft is generally unnecessary, but it is feasible if there exists seriously compressed fracture or big gap. In this series, 33 fractures were given bone graft and 9 were not. The materials used for bone graft
The therapies for calcaneal fractures include manual reduction plus plaster external fixation, percutaneous reduction by leverage plus round osseous pin fixation, and open reduction plus plate internal fixation. The former two methods may also be regarded as minimally invasive measures, but they can hardly make the needs of articular facet reduction. Open reduction by a large incision can achieve good reduction, but shortcomings are obvious, e.g. large injury, unhealed incision sometimes (8%-10% incidence). 3,4 Our open reduction
Chinese Journal of Traumatology 2010; 13(5):313-315
method by a small incision has the advantages of mild injury and good exposure to the calcaneotalar articular facet, therefore it facilitates to reach a good reduction. The method we used can thoroughly expose the subtalar joint. An anatomical reduction of the subtalar joint is essential for a successful surgical result. In order to minimize the incision, we consider that 3 methods can precisely design the position of the incision: (1) the activity and position of the subtalar joint can be seen by introversion or extroversion of the foot after anesthesia; (2) arthroscope-guided discission is useful to determine the position of incision and the condition of reduction; (3) the position of incision can be marked under C-arm fluoroscopy.
. 315 .
The philosophy of minimally invasive fixation is using as few as fixing devices and as simple as procedures to acquire maximum stability. Our mini-plate can provide a firm fixation for fractures at anterior and trochanter parts of the calcaneus, and sustentaculum tali. Since the plate is short and small in size, we recommend using 1-2 Kirschner wires or screws to fix the fractured bones at the subtalar joint for complex fractures. By transfixation of the calcaneus with the cuboid, the Gissane and Bohler angles can be retained and introversion or extroversion deformity be rectified.
REFERENCES 1. Sanders R, Fortin P, DiPasquale T, et al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results
In order to minimize the extent of injury from the operation, we adopted three reduction methods under C-arm fluoroscopy and arthroscopy: (1) manual reduction, in which the widening on the transverse axis and shorting on the longitudinal axis were corrected under anesthesia to restore preliminarily the Bohler and Gissane angles; (2) traction reduction, in which the round osseous pin or clipper was used to pass across the calcaneal tubercle for skeletal traction so as to correct the introversion or extroversion deformity of the calcaneus; (3) percutaneous reduction by leverage, in which the lateral articular facet was levered up and reposited with a round osseous pin or small elevator.
using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;(290):87-95. 2. Mulcahy DM, McCormack DM, Stephens MM. Intra articular calcaneal fractures: effect of open reduction and internal fixation on the contact characteristics of the subtalar joint. Foot Ankle Int 1998;19(12):842-848. 3. Zwipp H, Rammelt S. Posttraumatic deformity correction at the foot. Zentralbl Chir 2003;128(3):218-226. 4. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankel-hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int 1994;15(7):349-353. (Received February 5, 2010) Edited by SONG Shuang-ming
. 313 .
Minimally invasive plate internal fixation for calcaneal fractures SHAN Shu-lan 单淑兰, XU Jun-ling 许峻岭*, YAO Shu-zhang 姚书章, YU Guo-sheng 于国胜 and LIU Yu-qin 刘玉琴
【Abstract】Objective: To assess the clinical efficacy of minimally invasive plate internal fixation for the treatment of calcaneal fractures. Methods: Manual reduction, rectification of deformity, and cold compress with traditional Chinese medicine were used preoperatively to relieve swelling and pain. A small incision was made to expose the articular facet and to perform anatomic reduction and plate fixation. Self-made traditional Chinese pharmaceutics were applied postoperatively on the surface of the wound to accelerate bony union.
Results: All the 40 patients were followed up for at least 1 year postoperatively. According to the Maryland scoring system, the excellent and good rate was 87.5%. Conclusion: Minimally invasive plate internal fixation has the advantages of relatively mild injury, reliable fixation, good recovery, and rare complications in the treatment of intraarticular fractures. Key words: Surgical procedures, operative; Fracture fixtion, internal; Calcaneus; Manipulation, orthopedic Chin J Traumatol 2010; 13(5):313-315
C
alcaneal fracture accounts for 60% of all foot fractures and most of them (70%) are intraarticular fractures.1 Owing to the application of C-arm fluoroscopy during operation and internal fixation technique, substantial progress has been achieved in the treatment of calcaneal fractures. From January 2004 to January 2009, 42 intraarticualr calcaneal fractures in 40 cases were treated by minimally invasive plate internal fixation and the result has been proved satisfactory.
Preoperative management Emergency operation was performed within 24 hours after injury providing the general and local conditions allowed. If soft tissue swelling was obvious, the widening on the horizontal axis and shortening on the longitudinal axis of the calcaneus were manually corrected to restore Bohler and Gissane angles under general anesthesia. After manipulation, the affected limb was elevated and the wounded foot was given cold compress with gauzes immerged in self-made traditional Chinese pharmaceutics and freezed before use.
METHODS & RESULTS Demographics and fracture types There were 40 cases involving 42 calcaneal fractures, including 27 men and 13 women with the age ranging from 20-46 years and mean 35 years. According to Sanders classification,2 17 cases belonged to type II fractures, 23 type III fractures and 2 type IV fractures. The cause of injury consisted of fall injury in 22 cases, traffic accident in 15, and crush injury in 3.
DOI: 10.3760/cma.j.issn.1008-1275.2010.05.012 Department of Orthopedics, Cangzhou Intergrated Traditional and W estern Medicine Hospital, Cangzhou 061000, Hebei Province, China (Shan SL, Xu JL, Yao SZ, Yu GS, and Liu YQ) *Corresponding author: Tel: 86-13932720555, E-mail: [email protected]
Surgical indication All types II and III and some type IV calcaneal fractures as well as over 3 mm displacement of the articular facet could be treated by this method. Surgical procedures Patients with unilateral fracture were placed in lateral decubitus position and those with bilateral fractures were positioned prone. A 5-cm long incision was made parallelly with the subtalar joint or footplate with the midpoint located at 2 cm below the external malleolus to expose the bone. Care was taken not to damage the sural nerve. The long and short tendons of fibula were pulled out to the inferior part of the incision and thus the fracture site was revealed. The calcaneofibular ligament was cut off to expose the subtalar joint and lateral wall of the calcaneus. Schanz pin was used to
. 314 .
pass across the calcaneal tubercle for skeletal traction so as to correct the length and width of the calcaneus. Subsequently the traction orientation was adjusted inclined to the medial or lateral side based on the introversion or extroversion status of the calcaneal axis to rectify angulation deformity. A small periosteal detacher was inserted into the fracture interspace at the posterolateral wall to pry the lateral wall of the calcaneus and uncover the posterolateral articular fecet. The depressed posterior articular facet was reposited by leverage using a round osseous pin or an elevator. The reposited lateral articular facet was bound to the medial side using a 2 mm Kirschner wire to secure an anatomic reduction. Every bone fragment of the calcaneus from the calcaneal tubercle to the cuboid joint was transfixed. Under C-arm fluoroscopy, the position of the fractured bone and the length of screws were examined (Figures 1 and 2).
Chinese Journal of Traumatology 2010; 13(5):313-315
are homologous bone (Aorui Co, Shanxi, China) and artificial calcium phosphate bone (Ruibang Co, Shanghai, China). The fractured bone was fixed with 56 pore butterfly-type plates and thread screws. Screws at the anteriosupra plate were placed towards the direction of the sustentaculum tali and meanwhile bone fragments located at lateral calcaneus were fixed; screws at the anterioinferior position were fixed to the anterior part of the calcaneus and bone fragments involving in calcaneocuboid joint; screws at posterosuperior area for fixation of calcaneal trochanter; screws at middle part for fixation of the sustentaculum tali in an attempt to offer a reliable and firm hold. After recheck and confirmation of a satisfactory reduction by fluoroscopy, the drainage tube was left in situ and incision closed. Postoperative management Patients were given pressure dressing and wounded limbs were elevated postoperatively. Aescin or manicol was used if necessary. Self-made traditional Chinese pharmaceutics I consisting mainly of Carthamus tinctorius, Terrapin, etc and II consisting mainly of Himalayan teasel root, Myrrha, etc were taken orally. Nonweight-bearing functional exercise began the second day after operation. X-ray photographs were taken 8-12 weeks after operation. Once the fracture line disappeared on radiographs patients were allowed to weight-bearing ambulation with crutches.
Figure 1. The length of incision.
All the patients were followed up for 1-5 years. According to the Maryland scoring system, excellent results were achieved in 12 cases, good in 23 , fair in 4, and poor in 1, with the excellent and good rates of 87.5%. Necrosis or stripping of the epidermis was not found in any cases.
DISCUSSION
Figure 2. Fracture fixation is implemented.
Bone graft is generally unnecessary, but it is feasible if there exists seriously compressed fracture or big gap. In this series, 33 fractures were given bone graft and 9 were not. The materials used for bone graft
The therapies for calcaneal fractures include manual reduction plus plaster external fixation, percutaneous reduction by leverage plus round osseous pin fixation, and open reduction plus plate internal fixation. The former two methods may also be regarded as minimally invasive measures, but they can hardly make the needs of articular facet reduction. Open reduction by a large incision can achieve good reduction, but shortcomings are obvious, e.g. large injury, unhealed incision sometimes (8%-10% incidence). 3,4 Our open reduction
Chinese Journal of Traumatology 2010; 13(5):313-315
method by a small incision has the advantages of mild injury and good exposure to the calcaneotalar articular facet, therefore it facilitates to reach a good reduction. The method we used can thoroughly expose the subtalar joint. An anatomical reduction of the subtalar joint is essential for a successful surgical result. In order to minimize the incision, we consider that 3 methods can precisely design the position of the incision: (1) the activity and position of the subtalar joint can be seen by introversion or extroversion of the foot after anesthesia; (2) arthroscope-guided discission is useful to determine the position of incision and the condition of reduction; (3) the position of incision can be marked under C-arm fluoroscopy.
. 315 .
The philosophy of minimally invasive fixation is using as few as fixing devices and as simple as procedures to acquire maximum stability. Our mini-plate can provide a firm fixation for fractures at anterior and trochanter parts of the calcaneus, and sustentaculum tali. Since the plate is short and small in size, we recommend using 1-2 Kirschner wires or screws to fix the fractured bones at the subtalar joint for complex fractures. By transfixation of the calcaneus with the cuboid, the Gissane and Bohler angles can be retained and introversion or extroversion deformity be rectified.
REFERENCES 1. Sanders R, Fortin P, DiPasquale T, et al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results
In order to minimize the extent of injury from the operation, we adopted three reduction methods under C-arm fluoroscopy and arthroscopy: (1) manual reduction, in which the widening on the transverse axis and shorting on the longitudinal axis were corrected under anesthesia to restore preliminarily the Bohler and Gissane angles; (2) traction reduction, in which the round osseous pin or clipper was used to pass across the calcaneal tubercle for skeletal traction so as to correct the introversion or extroversion deformity of the calcaneus; (3) percutaneous reduction by leverage, in which the lateral articular facet was levered up and reposited with a round osseous pin or small elevator.
using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;(290):87-95. 2. Mulcahy DM, McCormack DM, Stephens MM. Intra articular calcaneal fractures: effect of open reduction and internal fixation on the contact characteristics of the subtalar joint. Foot Ankle Int 1998;19(12):842-848. 3. Zwipp H, Rammelt S. Posttraumatic deformity correction at the foot. Zentralbl Chir 2003;128(3):218-226. 4. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankel-hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int 1994;15(7):349-353. (Received February 5, 2010) Edited by SONG Shuang-ming