Calcaneal Fracture:Does a Limited Incision Result in Limited Reduction? Michael D. Dujela DPM, FACFAS Fellowship Trained Foot and Ankle Surgeon Washington Orthopaedic Center, Centralia, WA Chair, National Education and Scientific Affairs Committee American College of Foot and Ankle Surgeons Executive Committee, Global Foot and Ankle Community
Disclosures Consultant -Arthrex -I have no investments in medical industry companies -My presentation has been designed to be free of any actual conflict of interest with regard to the above relationships.
Questions to Answer… What is the evidence to support STA/Minimally Invasive approach? Should we change and if so why?
Lateral Extensile Approach Benefits Good Visualization + Reduction Concerns… ▪ Delayed ORIF ▪ Stiffness ▪ Healing time? ▪ Wound issues?
Technique for Minimally Invasive Approach
Why STA or Minimal Invasive? -#1 Predictor of poor outcome is poor motion Reduction in wound complications Comparable reduction/congruity Similar Outcomes Schepers T. Int Orthop. 2011;35(5):697-703 Schepers T. Int. Orthop. 2014;38(3):663-5
Indications? ▪ Sanders Type II/III ▪ Limited anterior comminution ▪ Soft tissue compromise ▪ Tongue type-PF intact
Timing? ▪ Day 1 until 2 plus weeks ▪ Who? Skilled and experienced ▪ Good spatial ability Average time to surgery=6 days post injury Buckley Int. Orthopaedics 2014
STA/MIRIF Current Evidence
STA-Percent Anatomic Reduction Study Number of <2 mm displacement Patients after repair Mostafa 2010 18 89% Ebrahim et al. 2000 106 72% Geel + Flemister 2001 32 97% Gupta et al. 2003 32 96% Hoospodar 2008 16 88% Weber et al. 2008 24 100% Spagnolo et al. 2009 39 74% Femino et al. 2010 13 100%
What is the Evidence? Lateral Extensile VS STA No difference Bohler’s Angle/ Angle of Gissane Kline AJ, Anderson, B et al FAI 34(6) 2013 More wound complications Basile A, Albo, F et al J Foot Ankle Surg 2016 More secondary Sx Similar Functional Outcome Scores Kumar et al. International Orthopaediccs 2014
Potential Disadvantages STA Direct visualization of the joints limited Tendency to accept imperfect reduction
48 y.o. Fall From Roof Perc. Approach Five years Post op
MS ▪ 52 YO male ▪ PMH: 0.5 pack/day cig. ▪ Rheum. Arthritis ▪ Fall from ladder 6 ft
Sinus Tarsi Approach Show post op with no collapse Loss of reduction at 15 weeks
Unstable Non Union
Higher rate of deep infection, post traumatic arthritis in low volume centers “An institutional load of less than one per month per center jeopardizes the outcome of the operative treatment of displaced intra-articular calcaneal fractures”
Which would you prefer for your own foot? Equivalent Functional outcome and Reduction.
Summary Start simple-Sanders II Technique oriented procedure, not technology driven!!
Summary Why change your approach? Why Expand your Armementarium? 2002 2017 2009 Lower rate of Wound Complications Allows Early Functional Rehab Evidence= STA Equivalent/better Anatomic Restoration than Lateral Ext.
THANK YOU
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