SLR - September 2012 - David Waters
Reference: Woon CY, Chong KW, Yeo W, Yeo NE, Wong MK (2011 Oct 21) The J Trauma: Injury, Infection and Critical Care 71(4): 917-925
Scientific Literature Review
Reviewed by: David Waters, DPM
Residency Program: St. John Hosptial and Medical Center Detroit, MI
Podiatric Relevance:
The goal in reduction of intraarticular calacneal fractures is restoration of the height of the posterior subtalar joint facet and Bohler’s angle. Traditionally, this has been done via open reduction and internal fixation. Along with this traditional method come certain morbidities including infection and wound dehiscence. Percutaneous reduction has been advocated to minimize these morbidities. The authors present a study of arthroscopy combined with percutaneous fixation using fluoroscopy to allow for better visualization of the posterior facet and thus allow for anatomic reduction while minimizing these potential complications.
Methods:
A prospective analysis of 22 patients with Sanders type 2, AO-OTA 83-C2 intra-articular calcaneal fractures underwent subtalar arthroscopic and intraoperative fluoroscopic guided percutaneous fracture fixation with minimum of two years follow-up. Patients were evaluated clinically preoperatively and postoperatively at three months, six months and two years for residual pain and function using the Ankle and Hind Foot Visual Analog Scale Pain Score, the Short Form, and the American Orthopedic Foot and Ankle Society Ankle Hind Foot Score. Radiographic assessment was performed utilizing digital radiographs including lateral, Harris-Beath, axial and Broden’s views preoperatively, immediately postoperatively, at six weeks, three months, six months, one year and annually thereafter.
Results:
There was significant improvement in Bohler’s angle form 4.2 degrees (+/- 11.1 degrees) preoperatively to 21.3 degrees (+/- 8.8 degrees) postoperatively with mean correction of 17.1 degrees (+/- 8.7 degrees). Reduction was maintained with slight decrease (20.1 degrees [+/- 8.2 degrees]) at two years postoperatively. There was suboptimal reduction in one patient with severe depression of the superolateral fragment and residual step off post reduction. Clinical subjective outcomes showed significant improvement in the three month VAS, AOFAS, and SF-36. These indices showed continued improvement with the two year values exceeding measurements of earlier time periods.
Conclusions:
The prospective analysis highlights early experience with dual modality subtalar joint arthroscopy and intraoperative fluoroscopy in the reduction of the posterior facet in Sanders type 2 and AO-OTA 83-C2 fractures. This study showed that joint congruence can be obtained with this highly skilled technique in simpler fracture patterns. However, it is associated with a steep learning curve. Morbidity of wound dehiscence and infection associated with open procedures is minimized by this technique. It is not known if this technique is adequate for more complicated or complex fracture patterns as ORIF may be a better way of treating these. In all cases the surgeon will need to weigh the risks and benefits of open vs. minimally invasive surgery.