What are the operative procedure steps for managing a calcaneal (calcaneum) fracture using plating?

From the Guidelines

The operative procedure for managing a calcaneum fracture with plating involves a lateral extensile L-shaped incision, careful elevation of a full-thickness flap, fracture reduction with restoration of the crucial angle of Gissane and Böhler's angle, and application of a pre-contoured calcaneal plate. The procedure steps are as follows:

• Positioning the patient in the lateral decubitus position with the affected foot elevated on a radiolucent support
• Making a lateral extensile L-shaped incision, starting 2 cm above the lateral malleolus, extending distally and then curving anteriorly below the fibula toward the calcaneocuboid joint
• Carefully elevating the full-thickness flap, preserving the sural nerve and peroneal tendons while exposing the lateral wall of the calcaneus
• Inserting a Schanz pin into the tuberosity to aid in fracture manipulation
• Identifying the subtalar joint and reflecting the lateral wall to visualize the fracture pattern
• Restoring the crucial angle of Gissane and Böhler's angle, with the posterior facet anatomically reduced using K-wires for temporary fixation
• Reducing the calcaneal body to the sustentaculum tali
• Applying a pre-contoured calcaneal plate to the lateral wall and securing it with locking and non-locking screws, as described in general orthopedic principles 1 However, it is essential to note that the provided evidence 1 does not specifically outline the operative procedure steps for managing a calcaneal fracture using plating, but rather discusses the diagnosis and treatment of heel pain, including the role of surgery in certain cases. The goal of this procedure is to restore calcaneal height, width, and articular congruity, which are essential for normal hindfoot biomechanics and to prevent long-term complications such as subtalar arthritis and peroneal tendon impingement. Postoperatively, the limb is elevated, and weight-bearing is restricted for 8-12 weeks depending on fracture healing.

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 an anatomically shaped interlocking calcaneal plate, which has been available in steel and titanium-molybdenum alloy versions since 2002 and 2003, respectively 3
• Employing a standard lateral approach for open reduction and internal fixation (ORIF) 4, 5
• Maintaining the articular surface of the posterior facet of the calcaneum and the crucial angle of Gissane 4
• Restoring the Bohler's angle and calcaneal height and width to achieve satisfactory results 4, 5

Key Considerations for Plating

Some key considerations for plating in calcaneal fracture management include:

• The use of locking compressive calcaneum plates, which can provide good outcomes, especially in less comminuted fractures 4
• The importance of maintaining the Bohler's angle, with angles between 21° and 40° associated with higher patient satisfaction 4
• The potential for complications, such as flap necrosis, infection, and subtalar arthritis, which can occur in a subset of patients 5

Surgical Approaches

Different surgical approaches can be used for calcaneal fracture management, including:

• The traditional extensile lateral approach, which offers advantages of achieving adequate fracture reduction but carries a risk of wound-healing complications and infection 2
• Limited open reduction and internal fixation techniques, which can minimize the risk of wound complications but may be associated with a higher risk of malunion 2