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سورة البقرة (32آية )

ANATOMICAL CALCANEAL PLATE IN MANAGEMENT OF DISPLACED INTRA-ARTICULAR CALCANEAL FRACTURES

By

Waleed Maher Ali 

MB, B.CH, RESIDENT OF ORTHOPEADIC SURGERY & TRAUMA FACULTY OF MEDICINE - MINIA UNIVERSITY

Thesis submitted in partial fulfillment of Requirement of M. Sc. degree in Orthopeadic& Trauma

Faculty of MedicineORTHOPEADIC SURGERY & TRAUMA Dept.

UNDER SUPERVISION OF

Prof. Hussein Abdel- Salam NazimPROFESSOR OF ORTHOPEADIC SURGERY &

TRAUMA FACULTY OF MEDECINE EL-MINIA UNIVERSITY

Dr. Ahmed Saleh Abdel-Fattah

ASSISTANT PROFESSOR OF ORTHOPEADIC SURGERY & TRAUMA FACULTY OF MEDICINE

MINIA UNIVERSITY

Dr. Mohamed Yehia HassanLECTURER OF ORTHOPEADIC SURGERY & TRAUMA FACULTY OF MEDICINE MINIA

UNIVERSITY

I would like to express my deep gratitude to the spirit of ..

Prof. Hussein Abdel- Salam Nazim

who patiently followed up and corrected the thesis, helping this work to come to light in proper form. Thanks for his continuous guidance.

Also I would like to express my deep respect to

Dr. Ahmed Saleh Abdel-Fattah , who helped and guided me in very hard

times in this work.

I would like to express my special thanks to ..

Dr. Mohamed Yehia Hassan,

who helped me in choosing the subject of this thesis and who kindly helped me with his valuable advice and great effort.

I would like to thank ..

Dr. HATEM GALAL ZAKIASSISSTANT PROFESSOR OF

ORTHOPEADIC SURGERY & TRAUMA –ASSUIT UNIVERSITY

For accepting to discus my thesis , giving us sharing time in his very

busy schedule and traveling to reach our university

I WOULD LIKE TO THANK

Prof. Dr. Mohamed ElshafaeiThe Head of the our Department of

Orthopedic surgery and trauma

I would like to thank our staff members in

orthopedic surgery and trauma dept. who

helped me so much by their experience

and guidance.

The calcaneus is the most frequently fractured

tarsal bone, accounting for 60% of all tarsal

injuries, and represents 2% of all fractures and

75% of calcaneal fractures are intra_articular.

Are bilateral in 5-9% of patients .

Incidence of associated injuries

such as compression fractures of

the lumbar and/or dorsal spine is

10% .

These fractures are complicated

by a compartment syndrome in

10% of cases.

Is to evaluate the results and

efficacy of the anatomical

calcaneal plate in treating

displaced intra-articular calcaneal

fractures .

ANATOMY OF THE CALCANEUS

1-BONY ANATOMY:

The calcaneus is the largest of the

tarsal bones It is irregularly cuboidal in

form, having its long axis directed

forward and lateralward

THE MEDIAL SURFACE

THE LATERAL SURFACE

On the superior aspect are three articular

surfaces: the posterior, middle, and anterior

facets. The posterior is the largest and is

convex. The middle one, which is slightly

concave, is situated on the sustentaculum tali.

The anterior facet, also slightly concave.

THE SUPERIOR SURFACE

2-RADIOLOGICAL ANATOMY

BÖHLER'S ANGLE

formed by drawing two lines. The first

is drawn from the highest point on the

anterior process to the highest point on

the posterior facet. The second line is

tangential to the superior edge of the

tuberosity. The normal value of Böhler's

angle is 25 to 40°.

THE CRITICAL ANGLE OF GISSANE

is the angle formed by the intersection

of a line drawn along the dorsal aspect

of the anterior process of the calcaneus

and a line drawn along the dorsal slope

of the posterior facet. The normal value

of Gissane's angle is 120 to 145°.

Lateral radiograph of the normal calcaneus. Lateral radiograph of the calcaneus shows compression (light blue arrows) and traction (yellow arrows) trabeculae,with the neutral triangle (brown triangle) in between with sparse trabeculae. The thickened cortical or thalamic portion of the bone supporting the articular facets is shown (T).

3 -Attachments & Relations:

4 -ARTICULATIONS:

TALOCALCANEAL JOINT )SUBTALAR JOINT( :

Lateral talocalcaneal ligament.

Medial talocalcaneal ligament.

Interosseous talocalcaneal ligament.

Cervical ligament

TALOCALCANEONAVICULAR JOINT

It is regarded as two joints, i.e. the anterior

part of the 'subtalar' joint and the

talonavicular joint.

CALCANEOCUBOID JOINT

at the same level as the talonavicular joint

and, together, they represent the transverse

tarsal joint.

5 -SURGICAL ANATOMY

The sural nerve runs about 3 cm above

the tip of the lateral malleolus.

The tendon of flexor hallucis longus

running under the sustentaculum tali of

the calcaneus.

BIOMECHANICS

The calcaneus contributes to :

The posterior aspect of the longitudinal

arch.

Supporting the talus.

Sharing in weight bearing.

Transmitting body weight to the ground

and creates a strong lever for the

muscles of the calf.

BIOMECHANICS OF SUBTALAR JOINT

Subtalar Joint

Subtalar Joint Motion

Axis of motion

passes obliquely

from posterolateral

aspect of calcaneus

through the neck of

the talus .

42° from transverse

plane

16° from sagittal

plane

Pronation of the

Subtalar joint

calcaneal abduction,

eversion and dorsiflexion

.

Supination of the

Subtalar joint

calcaneal adduction,

inversion and plantar

flexion

MECHANISM OF INJURY

intra-articular calcaneus fractures are usually the result of a fall from a height or an motor vehicle accident.

High-energy axial load, the talus is forced downward into the calcaneus

primary fracture line, or separation fracture, marked 1, runs from the critical angle of Gissane to the medial wall, dividing the calcaneus in the coronal plane. An additional fracture line is often seen extending from the anterior process to

the tuberosity 2

The shear fracture splits the calcaneus into the anteromedial (or sustentacular) and posterolateral (or tuberosity) fragments. The compression fracture runs in the coronal plane, with the anterior limb running through the critical angle of Gissane and the posterior limb extending either horizontally toward the tuberosity as a tongue type fracture (red line) or more vertically, just posterior to the posterior facet, as a joint depression type fracture (blue line).

CLASSIFICATION :

Essex-Lopresti (British Journal of Surgery 1952):

1- joint depression type

2 – tongue type

SANDER’S CLASSIFICATION

DIAGNOSIS:

Plain x-rays :

Lateral radiograph

Anteroposterior radiograph of the foot

Harris axial radiograph of the heel Patient

supine, foot maximally dorsiflexed, beam

45°cephalad

Oblique/Broden’s view

Brodén’s view

The articular surface

of the posterior

facet

CT

Coronal View

Sagittal View

Sanders type II A

Sanders type III AC

Sanders type IV

COMPLICATIONS

Early complications:

Significant Swelling

can develop

healing problems .

Compartment

Syndrome

Late complications:

chronic foot pain

difficulty with

certain types of

footwear

arthritis

TREATMENT

Calcaneus fractures are among the most difficult fractures to operatively reduce and internally fix.

Methods: Closed reduction, with elevation of the foot,

compression dressing, and early motion. Percutaneous reduction techniques such as

Essex-Lopresti . Open reduction and internal fixation as

popularized by Palmer et tal . Primary arthrodesis.

This prospective study was carried

out from December 2008 to July 2010 in

emergency section of our Department of

Orthopedic Surgery and Traumatology in

Minia University Hospital . We treated 30

patients with displaced intra articular

calcaneal fractures with anatomical plate

Age and sex: The age of the patients ranged between

22 and 40 years with the mean age 31 year , there were 18 cases below 31 years (60%) and 12 cases above 31 years (40%) . There were 22 males (73%) and 8 females (27%) .

Affected Side: The left side was affected in 10 patients

(33%), while the right was affected in 14 patients (47%) and it was bilateral in 5 patients (20%)

Mechanisms of Injury 25 cases were due to fall from hieght

)83%( and 5 cases were due to motor vechile accident )17%(

Classification systems: According to Essex-Lopresti there were 20

cases with joint depression type and 10 cases

with tongue type . According to Sander’s 18 (60%) type-II

fracture 8 cases (26%) were type III fractures and 4 (14%) cases were type IV fracture .

INCLUSION CRITERIA

Sanders types II or III .

Age 20 to 45.

Closed inra articular calcaneal

fractures.

Available for folloaw up for at least 2

years after surgeury.

Sanders types I or IV .

Medical contraindications to surgery,

Previous calcaneal pathology (infection,

tumor ) .

Open calcaneal fractures.

Injury greater than 3 weeks old .

Extra- articular fractures .

EXCLUSION CRITERIA

ANATOMICAL CALCANEAL PLATE

ADVANTAGES

Low-profile, 1.2 mm thickness may reduce

the potential for peroneal tendon irritation

and facilitates soft-tissue closure .

Reduced profile helps to simplifiy

intraoperative contouring

Calcaneal Plate’s Y-arm provides structural

support for joint depression fractures

K-wire holes allow for provisional stabilization

and verification of reduction

Central hole permits increased screw

angulation to allow for precise fixation of

sustentacular Tali

All plates are available in 50mm, 60mm and

70 mm lengths .

SURGICAL TECHNIQUE

Preoperative Planning :

Clinical examination of the affected

and contra-lateral limb .

Vascular examination .

Examination of the spine .

RESULTS

Criteria Grade Functional Results

no or mild pain, unlimited activities of

daily living and work, no difficulty with

walking on various surfaces, no use of

walking aids and normal range of motion

of STJ.

Excellent

moderate pain, slight limited activities

of daily living and work, slight difficulty

with walking on various surfaces, no use

of walking aids and slight decrease

range of motion of STJ.

Good

Severe pain, limitation of walk, work ability and decrease STJ motion usage of aids

Fair

Severe pain, Complete stiff STJ . Poor

FUNCTIONAL RESULTS

RADIOLOGICAL RESULTS

According To Bohler And Gissan’s Angle

Case one

Age: 25

Sex: Female

Classification: Type IIC , Joint Depression.

The affected side: RT

Mechanism of trauma: FFH

CASE PRESENTATION

POST OPERATIVE

6 MONTHS POST OPERATIVE

Case two

Age: 28

Sex: male

Classification: Type IIIAB, tongue-type .

The affected side: Lt

Mechanism of trauma: FFH

CASE PRESENTATION

Preoperative

POST OPERATIVE

6 MONTHS POST OPERATIVE

CASE PRESENTATION

Case Three

Age: 35

Sex: Male

Classification: Type IIIBC, Joint Depression

type .

The affected side: Lt

Mechanism of trauma: FFH

PRE OPERATIVE

As regard pre operative assessment of

our patients we agree with Leung et

al.that standard lateral, axial, and

internal oblique radiographs are not

adequate for the assessment of the

subtalar joint and CT is needed for

almost all fractures to detect the extent

and type of the fracture .

As regard the surgical approach used in

our study is the extended lateral

approach in all cases popularized by

Benirschke and Sangeorzan . The

merits of this approach involve the

inclusion of the peroneal tendon and

sural nerve with the flap, which helps

to minimize the risk of injury to these

structures.

The clinical outcome for 10 (33%) of the

30 feet was excellent and 15 (50%)

was good . 3 feet (10%) had a fair

result, and 2 were considered to have

had poor ; of these one feet, needed a

subtalar arthrodesis

The radiological resuls are 80% had

anatomical reduction, 13 % had near

anatomical reduction and 7 % had

failure of treatment. And thus we

consider 93% of cases are satisfactory

results and only 7% of cases are

unsatisfactory

Benirschke and Sangeorzan 2004(25 cases)

The bony results were five excellent (17.8%),

nine good (50.0%), two fair (11.1%), and two

poor (11.1%). .

The functional results were excellent in

(21.9%) patients, good in (43.7%), fair in

(12.5%), and poor in (21.9%).

(Zhongguo Xiu Fu 2008 reported on ( 50 cases)

The results were excellent and good in (88

%) , fair in (5%) and poor in (7%).

The results of Christoph are better

than our results this is due to the fact

that some of our patients were not

compliant during the follow up period

either by missing their follow up

appointments frequently or by starting

weight bearing too early before we

advise them to do so.

DISCUSSION OF COMPLICATIONS

Study Our Study Buckley et al 2002

Geel, Christoph 2005

Subtalar osteoarthritis

56% 65% 73%

Compartment syndrome

6% 28% 33%

Wound infections

12% 21% 25%

Pain 75% 84% 63%

As regard post operative complications

in our study, Injury of the sural nerve

has been reported in 3 cases (10%) ,

Infections , wound breakdown and late

deep infections occur in 30% of cases

and Subtalar osteoarthritis occurred in

6 cases (20%).

The focus of current treatment is on operative

methods, with the goal of restoring not only

articular congruency but also the shape and

alignment of the calcaneus and this can be easily

achieved by using the anatomical plate.

A lateral approach with use of an extensile

incision appears to be associated with the fewest

soft-tissue complications .

Intra operative fluoroscopy to obtain

Brodén’s, lateral, and axial radiographs

is strongly recommended to ensure an

anatomical reduction.

Thank

you