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 BIO70-04-C Effective: 3/2012 (888) 627-9957 www.acumed.net