SLIDE 1 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
SLIDE 2 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.
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Questions to Answer… Should we change and if so why? What is the evidence to support STA/Minimally Invasive approach?
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Lateral Extensile Approach
Benefits
Good Visualization + Reduction Concerns…
▪ Delayed ORIF ▪ Stiffness ▪ Healing time? ▪ Wound issues?
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Technique for Minimally Invasive Approach
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SLIDE 8 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
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Indications?
▪ Sanders Type II/III ▪ Limited anterior comminution ▪ Soft tissue compromise ▪ Tongue type-PF intact
SLIDE 10 Timing?
▪ Day 1 until 2 plus weeks ▪ Who? Skilled and experienced ▪ Good spatial ability
Buckley Int. Orthopaedics 2014
Average time to surgery=6 days post injury
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STA/MIRIF Current Evidence
SLIDE 12 STA-Percent Anatomic Reduction
Study Number of Patients <2 mm displacement 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%
SLIDE 13 What is the Evidence?
Lateral Extensile VS STA No difference Bohler’s Angle/ Angle of Gissane
More wound complications More secondary Sx Similar Functional Outcome Scores
Kline AJ, Anderson, B et al FAI 34(6) 2013 Basile A, Albo, F et al J Foot Ankle Surg 2016 Kumar et al. International Orthopaediccs 2014
SLIDE 14
Potential Disadvantages STA
Direct visualization of the joints limited Tendency to accept imperfect reduction
SLIDE 15 Five years Post op
48 y.o. Fall From Roof Perc. Approach
SLIDE 16 MS
▪ 52 YO male ▪ PMH: 0.5 pack/day cig. ▪ Rheum. Arthritis ▪ Fall from ladder 6 ft
SLIDE 17 Sinus Tarsi Approach
Show post op with no collapse
Loss of reduction at 15 weeks
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Unstable Non Union
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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”
SLIDE 21 Which would you prefer for your own foot?
Equivalent Functional
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Summary
Start simple-Sanders II
Technique oriented procedure, not technology driven!!
SLIDE 23 Summary
Why change your approach? Why Expand your Armementarium?
Lower rate of Wound Complications Allows Early Functional Rehab
2009 2002 2017
Evidence= STA Equivalent/better Anatomic Restoration than Lateral Ext.
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THANK YOU
