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ARTHROSCOPIC MANAGEMENT OF LATE COMPLICATIONS OF CALCANEALFRACTURES

Lui Tun HingNorth District Hospital

CALCANEAL FRACTURE

A primary fracture line that separates the sustentaculum fragment with the tuberosity fragment.

The sustentaculum fragment generally remains attached to the talus by the interosseous ligament.

The tuberosity fragment displaces superiorly and laterally, resulting in shortening and flattening of the calcaneus. It typically rests in a varusheel position.

Impaction of the talar body into the calcaneus can result in lateral cortical bulging

STEPHENS AND SANDERS CT CLASSIFICATION OF CALCANEAL MALUNION

Stephens and Sanders: Foot Ankle Int 17:395-401 Banerjee et al:J Am Acad Orthop Surg 19:27-36

OPERATIVE STRETAGIES TO DEAL WITH THE LATE COMPLICATIONS OF CALCANEALFRACTURE

Address all the deformities or

Concentrate on those aspects that are the most clinically pressing

ADDRESS ALL THE DEFORMITIES :RECONSTRUCTIVE OSTEOTOMY WITH SUBTALAR ARTHRODESIS

Romash MM, Clin Orthop Relat Res 290: 157-167.

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MULTIPLANE OSTEOTOMY TO ADDRESS LATERAL DISPLACEMENT AND SHORTENING OF LATERAL COLUMN

Hansen. Functional reconstruction of the foot and ankle. Philadelphia: Lippincott: 2000: 380-383

CONCENTRATE ON THOSE ASPECTS THAT ARE THE MOST CLINICALLY PRESSING

Stapleton et al. Clin Podiatr Med Surg 26:79-90, 2009

WHAT CANNOT BE PERFORMED ARTHROSCOPICALLY?

Subtalar distraction bone block arthrodesis and corrective osteotomy

Sural nerve neurolysis or resection

Resection of plantar exostosis

SUBTALAR DISTRACTION BONE BLOCK ARTHRODESIS AND CORRECTIVE OSTEOTOMY

Symptoms related to loss of height (dorsiflexedtalus with anterior ankle impingement) subtalardistraction bone-block arthrodesisarthrodesis

Symptoms related to loss of length (weakness of the ankle plantar flexion with easy fatigue of the calf muscle) of the bone corrective osteotomy is indicated.

Chen et al. J Trauma 45:729-737,1998

SUBTALAR DISTRACTION BONE BLOCK ARTHRODESIS

indicated in case of loss of >8 mm of heel h ight d di g hi id f t i height and radiographic evidence of anterior tibiotalar impingement

Myerson and Quill: J Bone Joint Surg 75 Am: 331-341, 1993

HOWEVER….

Myerson and Quill as well as Flemister et al cautioned against aggressive attempts to restore heel height as this may lead to hindfootg yvarus.

Others have argued that complete anatomic restoration of the hindfoot, based on talardeclination angle, is not necessary for a satisfactory outcome

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ARTHROSCOPIC MANAGEMENT

Do not focus on the correction of the talocalcaneal relationship or restoration of the height or length of the calcaneus.

Focus on the patient’s symptoms

Management of different impingement syndromes, subtalarand/or calcaneocuboid arthrosis, arthrofibrosis, post-traumatic synovitis and various peroneal tendon pathologies associated with calcaneal fracture.

For those patients with symptoms related to loss of height or length of the bone, corrective osteotomy or subtalar distraction bone-block arthrodesis is indicated

OPEN LATERAL OSTECTOMY FOR SANDER TYPE 1 MALUNION

Lateral calcaneal cortical bulging calcaneofibular or peronealimpingement syndrome or shoewear problems.

Clare MP, Lee III WE, Sanders RW, J Bone Joint Surg 87A: 963-973

ENDOSCOPIC RESECTION OF LATERAL CORTICAL BULGE

Three portals or two portals

Preoperative evaluation with CT scan and coronal 2D t ti th i d l li ti f reconstructions assess the size and localization of

the lateral calcaneal exostosis, its relations with the lateral malleolus as well as the extent of degenerative changes in the subtalar joint. plan the location of the portals and precisely know the localization and amount of bone resection that will be necessary (particularly in the lateral part of the subtalar joint)

TWO PORTALS TECHNIQUE

Bauer et al. Knee Surg Sports Traumatol Arthrosc 19:131–136, 2011

TWO PORTALS TECHNIQUE

Bauer et al. Knee Surg Sports Traumatol Arthrosc 19:131–136

CASE ILLUSTRATION

Lui TH, Knee Surgery, Sports Traumatology, Arthroscopy 2012, DOI: 10.1007/s00167-012-2086-3

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THREE PORTALS TECHNIQUE

Lui TH: Arch Orthop Trauma Surg 127:265–267, 2007

THREE PORTALS TECHNIQUE

Lui TH: Arch Orthop Trauma Surg 127:265–267, 2007

ARTHROSCOPIC IN SITU SUBTALARARTHRODESIS

Symptomatic subtalar arthrosis without hindfootmalalignment e.g after initial open reduction and internal fixation or Sanders type II malunion.

Talar dorsiflexion due to collapse of the posterior calcanealfacet was not contraindicated for this procedure if the patients did not report anterior ankle pain and who have no patients did not report anterior ankle pain and who have no pain anteriorly on forced passive ankle dorsiflexion or while squatting

Either with the lateral portals or posterior portals technique depending on the other planned arthroscopic procedures.

In case of Sanders type II malunion, endoscopic resection of lateral cortical bulge was also performed and lateral approach with anterolateral, middle and posterolateralportals were used.

IMPLANT IN SITU

In those cases with previous open reduction and internal fixation, the implant was not removed except those screws that blocked the placement of the arthrodesis screw.

OPEN DWYER CALCANEAL OSTEOTOMY FOR SANDER TYPE 3 MALUNION

In cases of Sanders type III malunion, calcanealosteotomy is frequently osteotomy is frequently performed in conjunction with the subtalar joint arthrodesis.

Clare MP, Lee III WE, Sanders RW, J Bone Joint Surg 87A: 963-973

PERCUTANEOUS DWYER OSTEOTOMY

Lui TH. The Journal of Foot and Ankle Surgery (in press)

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PERCUTANEOUS DWYER OSTEOTOMY

Lui TH. The Journal of Foot and Ankle Surgery (in press)

ARTHROSCOPIC SUBTALAR ARTHRODESIS WITH "CLOSING WEDGE PROCEDURE"

Correct the varus position by laterally based wedge resection of the subtalar joint during arthrodesis.

This was performed with the “closing wedge procedure” during the arthroscopic subtalararthrodesis.

Contraindicated if there is fixed forefoot eversion with respect to hindfoot

“CLOSING WEDGE PROCEDURE”

After the fusion sites are prepared, the Isham straight flute burr (VilexInc.) is inserted through the subtalar portals

Lateral wedge of bone is burred while applying valgus force to the heel and the varus heel is then corrected

However, further lateral impingement can occur The lateral gutter needed to be examined again after the “closing wedge procedure” and the lateral gutter was decompressed further if needed.

Lateral impingement can affect the closing up of subtalar joint after “closing wedge procedure”

Lui TH: Arch Orthop Trauma Surg 130:1007-1011, 2010

“CLOSING WEDGE PROCEDURE” VS PERCUTANEOUS CALCANEAL OSTEOTOMY

Not mutually exclusive “closing wedge procedure”: more focus on

correction of forefoot supinationp Percutaneous calcaneal osteotomy: more focus

on correction of varus heel My approach:“closing wedge

procedure”correct forefoot supinationpercutaneous calcaneal osteotomy if residual varus heel present

ARTHROSCOPIC TRIPLE ARTHRODESIS

Indicated in combined symptomatic calcaneocuboid and subtalar arthrosis.

It also may be indicated in the patient with preexisting deformity in conjunction with calcaneal malunion. A patient with preexisting flatfoot deformity and symptomatic calcanealmalunion may benefit from triple arthrodesis to correct the deformity and address the malunion

ARTHROSCOPIC TRIPLE ARTHRODESIS

Included arthroscopic arthrodesis of the subtalar joint, talonavicular joint, and calcaneocuboid joint.

Subtalar arthroscopy was performed through the anterolateral and middle subtalar portals.

The midtarsal arthroscopy was performed through the lateral, dorsolateral, dorsomedial, and medial portals.

Lateral and dorsolateral portals were established for calcaneocuboid arthroscopy. The talonavicular joint was approached through the medial, dorsomedial, and dorsolateral portals.

The hindfoot deformity can be corrected with the “closing wedge procedure” after preparation of the fusion surfaces.

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ARTHROSCOPIC TRIPLE ARTHRODESIS

Lui TH. Arthroscopy 22:464e1-464e5, 2006

ARTHROSCOPIC TRIPLE ARTHRODESIS

Lui TH. Arthroscopy 22:464e1-464e5, 2006

ARTHROSCOPIC TRIPLE ARTHRODESIS

Lui TH. Arthroscopy 22:464e1-464e5, 2006

ARTHROSCOPIC TRIPLE ARTHRODESIS

Lui TH Knee Surgery, Sports Traumatology, Arthroscopy 2012, DOI: 10.1007/s00167-012-2086-3

ARTHROSCOPIC SUBTALAR RELEASE

Subtalar arthrofibrosis with limited subtalar motion is common after calcaneal fracture especially in operated patients.

With a stiff subtalar joint, inversion eversion stresses are transferred to the ankle joint, especially the lateral ligamentous structures of the ankle. This compensatory stresses in the ankle joint, particular in the coronal plane of motion residual pain on the lateral side of the ankle and difficulty in walking on an uneven surface.

Arthroscopic subtalar release was indicated in patients with symptomaticsubtalar stiffness.

The tight lateral structure was released in stages to minimize the risk of over-release resulting in subtalar instability. The interosseous talocalcanealligament should be preserved during arthroscopic subtalar release. In addition, we perform quite extensive soft-tissue release, even extending beyond the surgical scar in the patients with previous open reduction, according to the intraoperative subtalar inversion motion gained.

Early vigorous subtalar mobilization and peroneal strengthening exercise are two important components of post-operative rehabilitation.

ARTHROSCOPIC SUBTALAR RELEASE

Lui TH. Arthroscopy 22: 1364.e1-1364.e4, 2006

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ARTHROSCOPIC DEBRIDEMENT OF THE ANTERIOR SUBTALAR, POSTERIOR SUBTALAR AND CALCANEOCUBOID JOINT

Post-traumatic synovitis of the subtalar and/or calcaneocuboid joint is one of the causes of lateral heel pain after calcaneal fracture.

The anterior subtalar joint synovitis is a commonly missed diagnosis. The joint(s) involved can be determined by clinical localization of the site of tenderness.

Arthroscopic synovectomy, resection of scar tissue and debridement of damaged cartilage can be performed through the corresponding arthroscopy

CLINICAL LOCALIZATION

The posterior subtalar joint synovitistenderness at sinus tarsi and lateral subtalar gutter.

The calcaneocuboid joint synovitislocal tenderness over the joint. A t i bt l iti Anterior subtalar synovitisusually presents with sinus tarsi pain sometimes also medial heel pain around the sustentaculum tali. Tenderness can be elicited by deep palpation of the soft spot between the talonavicular and calcaneocuboid joints and pointing posteromedially.

ANTERIOR SUBTALAR ARTHROSCOPY

Lui TH: Foot Ankle Int. 29:94-96Lui TH et al. Knee Surg Sports Traumatol Arthrosc. 18:233-237

MEDIAL SUBTALAR ARTHROSCOPY

Lui TH: Foot Ankle Int 33:1018-23, 2012Lui TH et al: Knee Surg Sports Traumatol Arthrosc (in press)

CASE ILLUSTRATION: CALCANEOCUBOIDDEGENERATION

ARTHROSCOPIC POSTERIOR ANKLE DECOMPRESSION: POSTERIOR ANKLE IMPINGEMENT Malunion of the joint depressed type calcaneal fracturethe bone spike

can form immediately posterior to the depressed posterior calcaneal facet + the thick scar tissue at the posterior ankle and can be pinched between the posterior tibial lip and the calcaneal bone spike during ankle plantarflexiondeep posterior ankle pain during activity with ankle plantarflexion plantarflexion.

The bony impediment and the scar tissue can be resected by means of a 2-portal posterior ankle endoscopy.

Because of the malunion of the calcaneum, the portals should be modified to override the posterosuperior corner of the calcaneum in order to reach the posterior part of the subtalar joint.

The posterior ankle scar tissue was resected. The posterior calcaneal facet was depressed and obscured by the bone spike just posterior to it. The subtalar joint cannot be visualized frequently. Intra-operative fluoroscopy is useful to identify the location of the bone spike and the posterior edge of the posterior calcaneal facet.

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ARTHROSCOPIC POSTERIOR ANKLE DECOMPRESSION

Lui TH. Knee Surg Sports Traumatol Arthrosc 16:687–689, 2008

ARTHROSCOPIC POSTERIOR ANKLE DECOMPRESSION

Lui TH. Knee Surg Sports Traumatol Arthrosc 16:687–689, 2008

ENDOSCOPIC CALCANEOPLASTY FOR IMPINGEMENT TO THE ACHILLES TENDON BY MALUNITED TONGUE TYPE CALCANEAL PROCESS.

Jung et al : open excision of the Haglund’s deformity for secondary Haglund’s deformity after malunion of tongue type calcaneal fracture.

Endoscopic calcaneoplasty: The resection of the posterosuperior process should be down to the insertion of posterosuperior process should be down to the insertion of the Achilles tendon since this is the site of impingement. Approach to the deep area can be facilitated by flexion of the knee and plantarflexion of the ankle during the procedure. Moreover, it is usually obscured by scar tissue between the bone and the Achilles tendon. This should be resected in order to gain adequate visualization of the Achilles insertion.

ENDOSCOPIC CALCANEOPLASTY

flexion of the knee and plantarflexion of the ankle during the procedure

Lui TH Knee Surgery, Sports Traumatology, Arthroscopy 2012, DOI: 10.1007/s00167-012-2086-3

ARTHROSCOPIC CALCANEOCUBOID DECOMPRESSION FOR CALCANEOCUBOID IMPINGEMENT

Residual bone overhang from the displaced anterolateral calcanealwall a loss of motion at the calcaneal-cuboid joint pain over the calcaneocuboid joint and increased stress to the adjacent joints.

Clare et al suggested that both the overhang as well as the lateral f h f h di l f h l h ld b d fourth of the distal aspect of the calcaneus should be removed, as the articulation of this lateral portion with the cuboid is almost always arthritic.

Calcaneocuboid arthroscopy: The portals should be modified according to the location and span of the overhang. They should be placed at the dorsal and plantar ends of the overhang. After removal of the overhang, the joint can be examined for any synovitis or cartilage damage. The joint pathology can then be treated arthroscopically. The extent of joint resection was titrated by the extent of cartilage damage.

ARTHROSCOPIC CALCANEOCUBOIDDECOMPRESSION

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ENDOSCOPIC RESECTION OF ANTEROSUPERIOR CALCANEALPROCESS FOR ANTEROSUPERIOR IMPINGEMENT

Occasionally malunited anterosuperior process with elongation of the process or unhealed fragment at this region can impinge on the plantar lateral side of the talarheadlocal swelling, deep pain and tenderness at that region and limited foot inversion.

Preoperative X rays (oblique view) of the foot is sufficient to confirm the diagnosis. CT may be needed if X rays cannot reveal the lesion. E d i i i f h i l l Th ki l h Endoscopic excision of the anterior calcaneal process: The working portal was at the junction between the talonavicular and calcaneocuboid joints. The visualization portal was either the anterolateral subtalar portal or the lateral midtarsal portal depending on whether there is any associated subtalar or calcaneocuboid joint problem.

It was important to examine the plantar lateral part of the talar head after resection of the process. Cartilage lesion was frequently present at this part of the talar head due to previous impingement by the calcaneal process. Arthroscopic debridement and microfracture can be done if the lesion was present.

This endoscopic technique also allowed detailed arthroscopic assessment of adjacent sites for possible concomitant lesions.

ENDOSCOPIC RESECTION OF ANTEROSUPERIORCALCANEALPROCESS

Lui TH. J Foot Ankle Surg. 50:476-9

PERONEAL TENDOSCOPY

Various acute peroneal tendon abnormalities can occur with intraarticularcalcaneal fractures and these include lateral displacement, bony impingement, subluxation or dislocation, hematomas and scar tissue formation, and entrapment of tendons

Peroneal tendonitis may occur secondarily by implant irritation when a lateral approach is used. It can present as pain over the lateral aspect of the lateral approach is used. It can present as pain over the lateral aspect of the heel. Buckling or giving way when walking also may suggest peronealtendon dysfunction.

Impingement or lateral displacement of peroneal tendons by underlying malunited calcaneal bone was indicated for endoscopic lateral calcanealostectomy.

Peroneal tendoscopy is indicated in case of post-traumatic synovitis, longitudinal tendon tear, traumatic peroneal tendons subluxation or dislocation. Endoscopic peroneal tendon decompression, tendon repair, synovectomy and retinaculum reconstruction can be performed

PERONEAL TENDOSCOPY

Lui TH. Knee Surg Sports Traumatol Arthrosc. 14:478-481, 2006Lui TH: Archives of Orthopaedic & Trauma Surgery. 132:357-61, 2012

NORTH DISTRICT HOSPITAL EXPERIENCE

Fifty patients (32 male, 18 female) with late complications of calcaneal fractures were managed arthroscopically between 2004 and 2009

All of the patients had had pain in the foot and ankle as a result of the calcaneal fracture, which had occurred at a result of the calcaneal fracture, which had occurred at a mean of 22 months (ranged, 7 to 45 months) before the arthroscopic surgery.

Conservative treatment with different modalities e.g. physiotherapy, insoles, shoewear modification and non-steriodal anti-inflammatory drugs were tried for at least three months before consideration of surgery.

Diagnosis Procedure Number of patientsMedian preoperative AOFAS ankle-hindfoot score (range)

Median postoperative AOFAS ankle-hindfoot score (range)

Calcaneofibularimpingement after Sanders

type 1 malunion

Arthroscopic lateral calcaneal ostectomy

14 65.5 (52-74) 97 (90-100)

Symptomatic Sanders type 2 malunion

Arthroscopic in-situ subtalar arthrodesis and

lateral calcaneal ostectomy2 46 85.5

Symptomatic subtalararthrosis

Arthroscopic in-situ subtalar arthrodesis

6 45 (32-56) 84 (74-94)

Symptomatic Sanders type 3 malunion

Arthroscopic subtalararthrodesis with “closing

wedge procedure” and arthroscopic lateral calcaneal ostectomy

2 38 73.5

Symptomatic subtalar and calcaneocuboid arthrosis

Arthroscopic triple arthrodesis

1 39 80

Symptomatic subtalar stiffness

Arthroscopic subtalarrelease

6 62.5 (52-66) 88.5 (84-97)stiffness release

Subtalar stiffness and calcaneofibular impingement

Arthroscopic subtalarrelease and lateral

calcaneal ostectomy3 68 (63-68) 97 (87-97)

Anterior and posterior subtalar pain,

calcaneofibular impingement, posterior

ankle impingement

Arthroscopic debridement of anterior and posterior

subtalar joints, arthroscopic posterior ankle

decompression and lateral calcaneal ostectomy

1 52 100

Calcaneocuboid synovitis, anterolateral impingement

Endoscopic resection of anterosuperior calcaneal

process, arthroscopic debridement of

calcaneocuboid joint

1 65 94

sinus tarsi syndrome, anterior subtalar arthrosis

Arthroscopic debridement of posterior and anterior

subtalar joints1 45 87

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Diagnosis Procedure Number of patientsMedian preoperative AOFAS ankle-hindfoot score (range)

Median postoperative AOFAS ankle-hindfoot score (range)

posterior and anterior subtalarjoint pain, calcaneofibularimpingement, secondary

Haglund deformity

Arthroscopic lateral exostectomy, arthroscopic

debridement of anterior and posterior subtalar joints,

endoscopic calcaneoplasty

1 59 88

calcaneocuboid degeneration, anterosuperior impingement, calcaneocuboid impingement

Arthroscopic debridement of calcaneocuboid joint,

arthroscopic calcaneocuboiddecompression, endoscopic resection of anterosuperior

calcaneal process

1 63 80

posterior ankle impingementArthroscopic posterior ankle

decompression1 75 100

posterior ankle impingement and Sanders type 1 malunion

Arthroscopic posterior ankle decompression and lateral

calcaneal ostectomy2 58 (58,58) 95(90-100)

posterior ankle impingement, Arthroscopic subtalar in situ

th d i th i 1 56 82p p g ,

subtalar arthrosisarthrodesis, arthroscopic

posterior ankle decompression1 56 82

secondary Haglund deformity endoscopic calcaneoplasty 1 62 90

calcaneocuboid impingement, calcaneofibular impingement

Arthroscopic lateral exostectomy, arthroscopic

calcaneocuboid decompression1 68 78

calcaneocuboid impingement, subtalar arthrosis

Arthroscopic subtalar in situ arthrodesis, arthroscopic

calcaneocuboid decompression1 37 76

calcaneocuboid impingement, Sanders type 2 malunion

Arthroscopic in-situ subtalar arthrodesis and lateral calcaneal

ostectomy, arthroscopic calcaneocuboid decompression

2 42.5(36-49) 82 (81-83)

Anterosuperior impingement, Sanders type 1 malunion with

far lateral degeneration

Arthroscopic lateral exostectomy, endoscopic

resection of anterosuperior calcaneal process

1 69 90

peroneal tenosynovitis Peroneal tendoscopy 1 67 87

PATTERNS OF PATIENTS’ PROBLEMS

Heterogenic. Certain patterns between the initial treatment and late

complications were observed, Those with initial casting or open reduction and internal

fixation tended to suffer from subtalar stiffness and fixation tended to suffer from subtalar stiffness and Higher chance of calcaneofibular impingement for those

patients with initial non-surgical treatment or closed reduction and screw fixation.

This is biased as the initial treatment was not randomized and was determined by the initial fracture pattern.

RESULTS

A median of 1 arthroscopic procedure was performed for each patient (range, 1 to 4).

The median follow-up after the latest arthroscopic surgery was 49 (range, 24-85 months) months.

RESULTS

Procedure Number of patients

Endoscopic resection of lateral cortical bulge 29

Arthroscopic in situ subtalar arthrodesis 12

Arthroscopic subtalar arthrodesis with "closing wedge procedure" 2

Arthroscopic triple arthrodesis 1

Arthroscopic subtalar release 9

Arthroscopic debridement of the posterior subtalar joint 3

Arthroscopic debridement of the anterior subtalar joint 3

Arthroscopic debridement of the calcaneocuboid joint 2

Arthroscopic posterior ankle decompression 5

Endoscopic calcaneoplasty 2

Arthroscopic calcaneocuboid decompression 5

Endoscopic resection of anterosuperior calcaneal process 3

Peroneal tendoscopy 1

RESULTS

In all of the cases, the symptoms improved the arthroscopic surgery

All the arthrodesis sites healed. Th ll di ti AOFAS kl The overall median preoperative AOFAS ankle-hindfoot score was 60.5 (27-75). The overall median AOFAS ankle-hindfoot score at the time of latest follow-up was 90 (73-100). The median gain of score was 30.5 (10-48).

COMPLICATIONS

One superficial wound infection

One sural nerve injury

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REPEATED ARTHROSCOPIC SURGERIES

were performed in two patients. Both of them had compensation issuesp One of them had two operations performed and

the other one had three operations. In each case, the patient’s complaint subsided after the operation and the other operation was performed for a new complaint.

SUMMARY

In this series, many patients have suffered from a combination of problems and combined procedures were needed.

Identification of the correct source of symptoms and proper selection of the appropriate procedures is the key to success.

Detailed history taking and clinical examination are the most important tools for decision-making.

SUMMARY: ARTHROSCOPIC LATERAL OSTECTOMY

Arthroscopic lateral ostectomy was the single most frequently performed procedure.

Because the integrity of the soft tissue envelope was preserved, soft tissue complication was minimized. Moreover, the associated subtalarpathology can be examined at the same time.

This procedure has been performed solely in 14 patients in this series with Sanders type 1 malunion with excellent results.

SUMMARY: IN-SITU SUBTALAR ARTHRODESIS

Subtalar joint arthrosis can occur even in anatomically reduced fractures due to cartilage damage from the initial trauma or penetration of the joint by implants.

Initial open reduction and internal fixation can restore calcaneal shape, alignment, and height and allow in situ calcaneal shape, alignment, and height and allow in situ subtalar arthrodesis.

In situ subtalar arthrodesis is also indicated for symptomatic Sanders type II calcaneal malunion.

Similar to the report of Mi et al, good union rate and clinical results with the arthroscopic subtalararthrodesis was observed in this series.

SUMMARY: CALCANEOCUBOID DEBRIDEMENT AND DECOMPRESSION

Arthritic calcaenocuboid joint is frequently asymptomatic.

Arthroscopic debridement was performed if the arthritic j i i f l d i d i h b ljoint was painful and not associated with subtalararthrosis.

The extent of joint resection was titrated by the extent of cartilage damage.

The result after arthroscopic debridement of the joints was difficult to evaluate because of the heterogeneity of patterns of procedures and patient’s symptoms. In our experience, it seemed that it depended on the extent of the cartilage damage.

SUMMARY: SUBTALAR RELEASE

Open subtalar release is not a good choice for symptomatic subtalar stiffness as the extensive surgical wound prohibits early vigorous

bili i i mobilization exercise.

Arthroscopic subtalar release has the advantage of smaller surgical wounds so that immediate vigorous mobilization is allowed

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SUMMARY: REOPERATION

The two cases of reoperation were not considered to be failure of the arthroscopic surgery as the patient’s symptoms subsided after operation in every episode.

The low reoperation rate in this series implies that a corrective operation to address all the deformities at the same time might be overdone.

LIMITATION OF THIS STUDY

Retrospective study without a control group for comparison.

The great varieties of individual pathology pattern make it difficult to draw conclusions about the effectiveness of arthroscopic management of different combination of pathology.

CLINICAL RELEVANCE

It provides a protocol of arthroscopic It provides a protocol of arthroscopic management of late complications following calcaneal fracture.

CONCLUSION

The arthroscopic approaches focused on the patient’s symptoms. It is a feasible approach to alleviate patient’s symptoms alleviate patient s symptoms.

Detailed history taking and clinical examination to determine the sources of the patient’s symptoms is the key to success.

BRING HOME MESSAGE

Most of the post calcaneal fracture foot pain is treatable

Follow up your patients, examine them carefully, offer the appropriate treatment

No matter conservative treatment, open or arthroscopic procedures

THANK YOU

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