Calcaneal fracture fixation: Extended lateral approach and locking plate fixation
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It is without question the case in orthopaedic trauma optimal outcome is closely associated with as near restoration of normal anatomy as possible as a starting point. That said when pursuing this worthy objective, it is of equal importance to :
A. Appreciate when reconstruction is not going to be attainable due to the nature of the primary injury
B.Identify when other extraneous factors are going to have a significant enough detrimental effect on your best endeavours to negate them. With calcaneal fractures smoking, non-compliance or inadequate vascular inflow being good examples.
C.Be realistic about your own limitations as a Surgeon, when dealing with rarer bony injuries, not only in terms of performing the surgery but also in advising patients what is or is not in their best interest.
Of those patients I’m aware of who do well (or very well) after displaced calcaneal fractures all have their anatomy restored to as near normal as possible. There are fracture patterns of course which will preclude this and the state of the soft tissues/timing of surgery and approach used are also key factors to consider.
I do not think there can be much argument that calcaneal malunion, especially significant malunion, has predictably detrimental effects upon mechanics of the subtalar joint, and on occasion also the ankle joint. This results in significant mechanical pain and disability, even without considering articular pain and arthritis. The primary cause of such calcaneal malunion is of course the calcaneal fracture, for arguments sake an unavoidable event. The secondary cause of calcaneal malunion however is not treating these injuries surgically, when it is appropriate to do so, which can be regarded as an avoidable event.
Complications can be significant but should be regarded, and counselled about, proportionately.
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Author:Mark Herron FRCS
Institution: The Wellington Hospital, London, Uk.