Percutaneous Calcaneoplasty in Displaced Intraarticular Calcaneal Fractures

1. Percutaneous Calcaneoplasty in
Displaced Intraarticular Calcaneal
Fractures
J Orthopaed Traumatol
Francesco Biggi
Level of evidence IIb
PRESENTER : Dr SAUMYAAGARWAL
Junior resident Dept of Orthopaedics J.N. Medical College
and Dr. Prabhakar Kore Hospital and MRC, Belgaum

2. INTRODUCTION
• Calcaneum is the most frequently fractured
tarsal bone,
accounting for about 2 % of all fractures,
often derived from high-energy trauma in
young patients.
• The ideal treatment for displaced
intraarticular calcaneal fractures remains
controversial.

3. • Open reduction internal fixation is the most
popular surgical approach.
• A lateral approach is used to expose fragments,
obtain reduction, and stabilize by plating with
additional bone grafting .

4. • Soft tissue complication is a major concern
due to thin and vulnerable skin over lateral
calcaneal wall which is cut and retracted
during surgery and jeopardized by underneath
plate.
• Rate of complications is between 15 to 25 %.

5. Authors started the application of Kyphon
(Medtronic) tools, in association with minimally-
invasive techniques,
for closed reduction of Sander’s type II and III
fractures and
balloon-assisted augmentation with both acrylic
cement and calcium phosphate
(minimally- invasive percutaneous calcaneoplasty).

6. SANDER’S CLASSIFICATION

7. ESSEX LOPRESTI CLASSIFICATION

8. OBJECTIVES
(1) To minimize surgical trauma by reducing
complications,
(2) To standardize the technique,
(3) Avoid immobilization by encouraging early
function
(4) Allow partial to full weight-bearing in 4–6
weeks.

9. MATERIALS AND METHODS
Retrospective study was done with 11 patients,
7 female and 4 male
with a mean age of 58.4 years (from 28 to 81 yrs)
who sustained displaced intraarticular calcaneal
fractures and were treated with minimally-
invasive percutaneous calcaneoplasty
from January 2008 to June 2010 .

10. • Preoperatively, conventional X-rays and CT
scan with 2D and 3D reconstructions were
obtained in all cases.

11. Lateral preoperative radiograph of a Sanders type
III fracture

12. Preoperative CT scan reconstruction showing
vertical displacement of joint surface

13. • Out of 11 , 6 fractures were classified as
Sanders type II and 5 as type III.
• 7 cases had a fall from height on hard ground
and remaining had motor vehicle accidents.
• Conventional X-rays were performed
postoperatively and at 6–8 weeks.
• Then with a CT scan at 1 year when full weight-
bearing is allowed and at the last follow-up.

14. Postoperative lateral radiograph showing
reconstruction
and restoration

15. • The American Orthopaedic Foot and Ankle
Society (AOFAS) ankle/hindfoot score was used
for clinical evaluation.
• Graded as Excellent (90), Good (80), Fair (70)
and poor (<70)
• Bohler’s angle was calculated to assess bone
reduction.

17. Bohler’s Angle
The angle is normally between 20 and 40 degrees; a decrease in
this angle indicates that the weight-bearing posterior facet of the
calcaneus has collapsed, thereby shifting body weight anteriorly.

18. ANGLE OF GISSANE
The normal angle is between 95 and 105 degrees; an
increase in this angle indicates collapse of the
posterior facet

19. Operative Technique
• A 2-cm incision is made on the lateral-posterior
calcaneal wall and sinus tarsi is approached by
visualizing depressed articular surface.
• Usually a smooth periosteum elevator is used
under image intensifier control to lift and
relocate the articular process.
• Temporarily stabilization was done with K-
wires.

20. • Varus malalignment can be managed by single
manipulation or with help of Steinman pin
insertion in the tuber perpendicular to
longitudinal axis of the calcaneum.
• Then a cannula is placed into the body followed
by insertion of a bone tamp attached to a digital
manometer (Kyphon, Medtronic, Minneapolis,
MN, USA).
• The balloon is inflated gradually under
fluoroscopy.

22. • Now bone cement is prepared
immediately prior to its injection into the
defect and the balloon is removed.
• No cast is applied.
• Patients encouraged to actively bend the
ankle with assisted weight-bearing and
discharge in 2–3 days.

23. Reduction of subtalar joint with periosteum
elevator under
image intensifier control

24. Intraoperative view demonstrating
position of the balloon

25. RESULTS
• All cases progressed to bony union in 2–3
months.
• According to AOFAS score, clinical results were
excellent in 6 cases, good in 4 and fair in 1.
• Considering a normal Bohler’s angle between
20 and 40,
• the mean preoperative value was 9.91
• while the mean postoperative was 22.97

26. • Patients returned to work between 10 and 12
weeks.
• No wound complications or adverse reactions
were observed.

27. DISCUSSION
• Calcaneal morphology and height are essential
for hindfoot and ankle function and fracture
reduction.
• Recreating a congruent subtalar joint is
mandatory.
• ORIF via extended lateral L-type retro-
malleolar approach and plate fixation, is still
most popular method, reporting good to
excellent results in 60–85 % cases.

28. • Treat displaced but reconstructable articular
calcaneus fractures by minimally invasive
percutaneous lateral approach,
• Obtaining reduction by manipulating
fragments under fluoroscopy,
• and finally stabilizing the subtalar surface by
injecting cement or a more biologic but
resistant material (calcium phosphate).
• Literature about this new minimally-invasive
technique is very poor.

29. CONCLUSION
• Minimally-invasive percutaneous
calcaneoplasty can represent an alternative to
open reduction internal fixation
• in the treatment of calcaneal fractures,
• allowing stable reduction without plating,
• early function recovery and
• short hospital stay.