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1、2021/7/27 星期二1Preop lateral demonstrating joint depression type of fracturewith displacement of a tuberosity and extension into the calcaneal cuboid joint.2021/7/27 星期二2The 30 degree semi-coronal and axial CAT scans of the fracture.TALUSDISPLACED POSTERIOR FACETINTACTPOSTERIOR FACETSECONDARY FRACTUR
2、E LINETUBEROSITYANTEROLATERALFRAGMENTTHALAMIC(SUSTENTACULAR)FRAGMENTDISPLACEDPOSTERIOR FACET2021/7/27 星期二3The patient is positioned carefully in the lateral decubitusposition with pads under the axilla and downside peronealnerve.The down leg is placed forward against and parallelwith the anterior ed
3、ge of the bed.2021/7/27 星期二4Pillows are placed between the legs and enough sheetsbehind the down leg such that the operative leg lies parallel with the ground and at the level of the patients hip.2021/7/27 星期二5The wrinkle test,as described by Sanders,involves dorsiflexingthe foot from a plantar-fixe
4、d position and looking for normal skin turgor,as evidenced by wrinkling of the skin along the area of the lateral part of the foot.2021/7/27 星期二6ANTERIORACHILLESBORDERINCISIONPERONEALTENDONSFIFTHMETATARSALThe incision is slightly curved and L-shaped,beginning just anterior to the Achilles,curving at
5、 the level of the skin color change,running parallel with the sole of the foot and then curving slightly up anteriorly at its distal extent.FIBULA2021/7/27 星期二7With the tourniquet inflated,the corner of the incision is brought directly down to bone.2021/7/27 星期二8ABDUCTORFASCIAToward the distal exten
6、t of the incision the fascia of the abductor should be identified and dissection should be performed superficially to this so as not to devascularize the muscle layer.2021/7/27 星期二9In order to dissect directly on the calcaneus in a subperiosteal manner,significant tension should be developed by hold
7、ing the heel inverted with the thumb and pulling directly laterally awayfrom the foot with a sharp retractor held deep in the flap.2021/7/27 星期二10TENSIONThe tension as developed allows for easy dissection in asubperiosteal manner,with a knife that is held essentiallyparallel with the bone.Many#15 bl
8、ades will be necessaryin order to dissect out the entire calcaneus.2021/7/27 星期二11PERONEALTENDONSAfter the flap is completely elevated,the peroneal tendons arevisible at the distal extent of the flap.Care must be taken notto damage these tendons as the dissection progresses distally.2021/7/27 星期二12L
9、ATERAL PROCESSOF TALUSCloseup view demonstrating that with flap elevation the lateral process and posterior facet of the talus is identified.A K-wire is placed into the talar body from the lateral process and used to retract the flap.2021/7/27 星期二13PIN IN FIBULAPIN INTALUSDISPLACEDPOSTERIORFACETThe
10、lateral wall and displaced portion of the posterior facet of the calcaneus us removed.2021/7/27 星期二14TUBEROSITYINTACT POSTERIORFACET OF CALCANEUSPOSTERIORFACET TALUSDISPLACEDPOSTERIORFACETA bone hook can be used to pull the tuberosity down to its normal position;this reduction is necessary to allow
11、for reduction of the posterior facet without steric interference.2021/7/27 星期二15TUBEROSITYINTACT POSTERIORFACET OF CALCANEUSPOSTERIORFACET TALUSDISPLACEDPOSTERIORFACETIn this figure,the posterior facet of the talus is visible with theintact medial portion of the posterior facet of the calcaneus rema
12、ining in its reduced position.The fractured lateral portionof the facet is visible as it is being removed.2021/7/27 星期二16K-WIREFREERELEVATORAfter cleaning the fragment,the posterior facet is reducedanatomically with the aid of a Freer elevator in palpatingthe reduction,which is sometimes very diffic
13、ult to see.This is held in place with a K-wire2021/7/27 星期二17K-WIREFREERELEVATOROnce the reduction is confirmed under direct vision and fluoroscopy,it is fixed with cortical lag screws(next image).The fracture is anatomically reduced and visible with forceful inversion of the heel.2021/7/27 星期二18POS
14、TERIORFACET TALUSPOSTERIOR FACETREDUCTIONA head lamp can direct light against the posterior facet of thecalcaneus by reflecting it off the posterior facet of the talus.2021/7/27 星期二19The lateral x-ray demonstrating K-wire holding the tuberosity inposition.Also note a K-wire in the area of the angle
15、of Gissane,holding the anterolateral fragment reduced.2021/7/27 星期二20Reduction of the anterolateralfragment is usually obtainedby forceful manipulation witheither a ball spike or periostealelevator.A K-wire can thenbe placed in the anterolateralfragment into the intact medial sustentacular fragment(
16、arrow).ANGLE OFGISSANE2021/7/27 星期二21The lateral wall fragments are pieced back as well aspossible,given that they are sometimes comminuted.2021/7/27 星期二22Lateral radiograph and clinical picture after the anterolateral and anterior portion of calcaneus have been fixed with lag screws,demonstrating r
17、eduction of the facet,the anterior calcaneus and the tuberosity.2021/7/27 星期二23After the bone is repositioned and held in place with K-wires,it is plated.In this example,two mini-fragment platesare used.However,many options are available for the platefixation.2021/7/27 星期二24Lateral radiograph after
18、initial plate fixation.2021/7/27 星期二25The closure is exceedingly important and must be done inseveral layers.The deep fascia must be repaired to theperiosteum of the flap with interrupted sutures.2021/7/27 星期二26DRAINThe sutures should all be placed and tagged,then closed from the distal extent of the wound towards the apex to continually remove tension from the flap during the closure.The closure should be performed over a Hemovac drain.2021/7/27 星期二27Intraoperative plain radiographs in the lateral and APplane demonstrate reduced calcaneus.2021/7/27 星期二28