From the Guidelines
The operative procedure for managing a calcaneum fracture with plating involves several key steps, prioritizing anatomical reduction and stable fixation to minimize morbidity and mortality, and optimize quality of life. The patient is positioned in the lateral decubitus position with the affected foot elevated on a radiolucent support. After standard surgical preparation and draping, an L-shaped lateral approach (extended lateral approach or Palmer approach) is utilized, creating a full-thickness flap to expose the lateral wall of the calcaneus. Care is taken to protect the sural nerve and peroneal tendons during dissection. Once exposed, the fracture is visualized and any impacted fragments, particularly the sustentaculum tali, are identified. The articular surface is then reduced anatomically using K-wires, bone tamps, and elevators to restore Bohler's and Gissane's angles. Temporary fixation is achieved with K-wires. After confirming reduction with fluoroscopy, a pre-contoured calcaneal plate is applied to the lateral wall. Multiple screws are placed through the plate into the tuberosity, sustentaculum tali, and anterior process to provide stable fixation. The subtalar joint reduction is verified, and bone grafting may be performed to fill any defects. The wound is thoroughly irrigated, and layered closure is performed with careful attention to the soft tissues. A well-padded splint is applied with the ankle in neutral position. Postoperatively, the limb is elevated, and a non-weight-bearing protocol is followed for 8-12 weeks, with progressive weight-bearing thereafter based on radiographic evidence of healing. Complications to monitor include wound healing problems, infection, and subtalar arthritis. Although the study by 1 provides general guidance on the diagnosis and treatment of heel pain, including calcaneal fractures, it does not specifically outline the operative procedure steps for plating, emphasizing the need to rely on more specialized and recent orthopedic guidelines for optimal management.
Some key considerations in the operative procedure include:
- Anatomical reduction of the articular surface to restore Bohler's and Gissane's angles
- Stable fixation using a pre-contoured calcaneal plate and multiple screws
- Protection of the sural nerve and peroneal tendons during dissection
- Verification of subtalar joint reduction and potential bone grafting
- Careful attention to soft tissues during wound closure and postoperative management.
From the Research
Operative Procedure Steps for Managing Calcaneal Fractures using Plating
The operative procedure steps for managing calcaneal fractures using plating involve several key considerations, including:
- Achieving anatomic reduction and minimizing complications of the compromised soft tissue envelope 2
- Using a traditional extensile lateral approach or a less invasive reduction and fixation via a sinus tarsi approach 3
- Maintaining the articular surface of the posterior facet of the calcaneum and the crucial angle of Gissane 4
- Restoring the height, length, width, and axis of the heel bone 5
Steps Involved in the Operative Procedure
The steps involved in the operative procedure for managing calcaneal fractures using plating include:
- Open reduction and internal fixation (ORIF) using a calcaneal locking compression plate (LCP) from an extended lateral approach 5
- Filling central cancellous bone defect areas with calcium phosphate bone substitute material or other materials 5
- Achieving primary stable osteosynthesis and enabling early mobilization 5
- Using a minimally invasive approach featured the concept of internal compression, including an anatomic plate and multiple compression bolts 6
Considerations for the Operative Procedure
Considerations for the operative procedure include:
- The timing of surgery, with urgent surgical intervention necessary in open fractures or those with compromised soft tissues 5
- The use of pre- and post-operative CT scans to evaluate the fracture and classify it according to the Sanders classification system 5
- The risk of early complications, such as wound dehiscence, necrosis of wound edges, and early superficial infection 5
- The importance of good timing and careful consideration of indications and contraindications for surgery 5