Case Series: Calcaneal Fracture Solutions

Case Series: Calcaneal Fracture Solutions
Treatment Options From Acumed®:
Locking Calcaneal Plate
Acutwist®
Acutrak® 6/7
Callos® Calcium Phosphate Cement
The information found within this material(s) contains the opinion of a
medical professional. Compensation was made to the consulting medical
professional for the creation of this case series.
Case Series: Calcaneal Fracture Solutions
Indication: Calcaneal Fracture ORIF
Products: Acutrak® 6/7 Screws, AcuTwist®, Callos® Impact Calcium Phosphate Cement.
Surgeon: Nicholas A. Abidi, M.D., Santa Cruz Orthopaedic Institute, Capitola, CA
Patient History
Postoperative Results and Outcome
A 56-year-old male patient fell off of a diesel truck while attempting to repair the engine. The fall
was approximately six feet onto the left heel and left elbow. Radiographic evaluation shows that
the patient sustained closed Ipsalateral fractures of the left heel (Figure 1) and left radial head.
Figure 2 shows films taken at six week follow-up. The patient was free of swelling
normally noted with the traditional ORIF approach and was able to advance to full weight
bearing and start aggressive physical therapy.
Treatment
Discussion and Conclusion
The patient received non-operative management for the radial head type I fracture. Open
reduction and internal fixation (ORIF) of the calcaneus was performed within five days, as
soon as swelling resolved. A lateral sinus tarsi incision was made followed by reduction of
the sustentaculum and posterior facet to match the undersurface of the talus. Fragments
were pinned with K-wires and Acutwist® screws were used to compress the posterior
facet fragments against the sustentaculum. For cases with significant osteoporosis
laterally, Acutrak® 2 Standard or Acutrak® 2 Mini screws are often used.
Clinical and biomechanical studies support using Calcium Phosphate Cement
augmentation in patients with these type of injuries.1 The technique of intramedullary
headless screw fixation for calcaneal fractures has also been demonstrated as being
superior to nonlocking plate fixation in a cadaver study.2
The posterior facet was elevated from plantar to dorsal and held in an elevated position
with a lamina spreader through a lateral incision. The fracture void was then filled with
Callos® Impact Calcium Phosphate Cement. The length, width and valgus alignment
of the calcaneal body was maintained with axial 6/7 guidepins. The first pin was
placed medially from the plantar medial heel into the constant fragment beneath the
sustentaculum. The second pin was placed plantar and lateral into the anterior lateral
calcaneum process.
Placement of both guidepins was confirmed by mini-fluoroscopy with lateral and axial
views. The headless Acutrak® Compression Screws were predrilled and placed through
two small stab incisions. The conical shape of the screw supports the internal structure
of the calcaneus. This approach permits a Minimally Invasive Surgical (MIS) incision
technique that limits wound healing complications noted with the traditional Seattle
incision. In addition, minimal manipulation of the peroneal tendons permits early range
of motion with less deep tissue scarring. This minimalist approach permits ease of subtalar
arthrodesis, if necessary, in the future through the same incision.
Figure 1 Pre-op
Patients undergoing this technique may have less swelling and wound healing
complications than with the traditional approach. We have witnessed solid fracture
consolidation in the majority of patients by six weeks post-op (Figure 3). In addition,
patients have less stiffness and pain at the twelve week follow-up.
Standard principles of joint reduction, re-establishment of Bohler’s angle and solid
fixation associated with the traditional approach to calcaneal fracture reduction and
fixation must be adhered. Sanders type IV fractures should still be considered for
primary subtalar arthrodesis in addition to fracture fixation. The MIS approach should
be attempted by surgeons skilled in calcaneal fracture management and arthritic
reconstruction of the hindfoot. Arthroscopy and fluoroscopy can be utilized to confirm
intra-operative reduction of the fracture and placement of hardware.
Figure 2 Post-op Week Two
1. Thordarson DB, Bollinger M: SRS cancellous bone cement augmentation of calcaneal fracture fixation. Foot Ankle Int 2005:26:347-352.
2. Nelson JD, McIff TE, Moodie PG, Iverson JL, Horton GA: Biomechanical stability of intramedullary technique for fixation of joint depressed calcaneus fracture. Foot Ankle Int:31:229-235.
Figure 3 Post-op Week Six
Case Series: Calcaneal Fracture Solutions
Indication: Right Calcaneus Fracture
Products: Acumed® Locking Calcaneal Plate and Callos® Inject Calcium Phosphate Cement
Surgeon: Darin Friess, M.D., Oregon Health Sciences University, Portland, OR
Patient History
Postoperative Results and Outcome
A 50-year-old obese male (BMI 36) was involved in a motor vehicle collision. He
sustained multiple injuries including an unstable fracture of the thoracic spine, pelvic
ring disruption, left acetabulum fracture, and right calcaneus fracture (Figure 1). After
stabilization of his spine, pelvis and acetabulum fractures, we discussed treatment
options for his right calcaneus fracture. The fracture angulation in varus, displacement of
Bohler’s angle, and articular surface comminution were predictive of a poor outcome if
treated nonsurgically. Additionally, since the left sided acetabulum fracture would require
prolonged non-weight-bearing, rigid fixation of the right calcaneus fracture would allow
earlier mobilization on the right leg. Thus, the patient was taken to the operating room for
open reduction and internal fixation (ORIF) of the right calcaneus fracture.
Intra-operative fluoroscopy views demonstrate the reduction of the calcaneus fracture
after plate and screw fixation with a large central cancellous bone void filled with Callos®
(Figure 3). The patient was allowed to transfer from bed to chair using his right foot for
mobilization purposes. Radiographs at the five month postoperative mark demonstrate
no collapse of the fracture and excellent signs of early radiographic healing. The patient
has no pain in his foot at this point and is very happy with the result.
Treatment
Surgical ORIF of the right calcaneus fracture was performed through a standard lateral
approach to the heel. The articular surface was reduced and stabilized using free lag
screws. An Acumed® precontoured low-profile calcaneal plate was placed laterally with
a combination of lag screws and locking screws. Finally an approximately 5cc sized
cancellous bone void was filled with Callos® Inject Calcium Phosphate Cement. Despite
this patient’s obesity and contralateral leg injuries, the Callos® cement combined with
the locking calcaneal plate provided a stable platform for early mobilization on the
right leg (Figure 2).
Figure 1 Pre-op
Figure 2 Immediate Post-op
Discussion and Conclusion
Surgical treatment of the calcaneus fracture restored normal anatomical alignment and
articular reconstruction to the hindfoot and led to an excellent outcome for this patient.
Although not FDA approved for weight-bearing applications, Callos® cement provides
an immediately stable platform to buttress the articular reconstruction, which prevents
collapse during the period of early fracture healing. The Callos® will remodel over
time and avoids ethical or infectious issues associated with cancellous bone graft. The
precontoured Locking Calcaneal Plate provides an opportunity to place both nonlocking
and locking screws in a low-profile plate to maintain the surgical alignment of the
calcaneus and reduce postoperative complications.
Figure 3 Five Month Post-op
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