Joint-Sparing Surgical Management of Sanders IV Displaced Intra-Articular Calcaneal Fractures

Key points

Joint-sparing surgical management of Sanders IV displaced intra-articular calcaneal fractures

Chen and colleagues⁴¹ described performing ORIF through a lateral extensile incision in 26 Sanders III and 32 Sanders IV fracture pattern DIACFs. Mean time from injury to surgery was 10 days (range: 7–14 days). The mean patient age was 29.5 years (range: 17–58 years). The mean follow-up was 13 months (range: 6–24 months). Complications developed in 8 patients, including 2 incisions with superficial necrosis, 2 instances of advanced subtalar joint post-traumatic arthrosis, and 4 feet with

Surgical technique: open reduction with internal fixation

Surgery must be delayed until the soft tissues are conditioned for surgery, and this delay can approach 2 weeks when extensive hemorrhagic blistering is present (Fig. 4). One should perform this procedure with the patient in the lateral or lateral-decubitus position. Tourniquet control is usually necessary. An extensive L-shaped incision is employed as described by Borrelli Jr and Lashgari,⁴⁵ respecting the arterial supply to the full-thickness soft-tissue flap,46, 47 which is elevated

Surgical technique: closed manipulation, intraosseous reduction and CALCANAIL fixation

One should perform this procedure with the patient placed in the prone position under general anesthesia. Tourniquet control is not necessary. Under intraoperative C-arm image intensification, a guide wire with stopper is driven into the posterior tuberosity aiming toward the lateral process of the talus, since the critical angle of Gissane is unrecognizable with Sanders IV fracture patterns (Fig. 7A), and on the axial view within the center of the calcaneal tuberosity axis and parallel to any

Complications and concerns

The most common, and feared, complications associated with ORIF of Sanders IV pattern DIACF are wound-related skin flap necrosis, dehiscence, and secondary deep infection, as these sequelae can result in below-knee amputation.48, 56 Failure to restore calcaneal morphology, especially malunion, results in poor clinical outcomes and complicates future surgery.⁵ Inadequate restoration of the posterior subtalar joint facet articular surface and avascular necrosis of the posterior subtalar joint

Summary

Sanders IV DIACFs represent the most challenging fracture pattern for the most challenging fracture in the foot. The damage sustained to the soft tissues, bone, and cartilage are irreversible and life-altering. ORIF with primary subtalar arthrodesis represents the last definitive operative procedure. Unfortunately, the available literature for this approach using the extensile lateral approach demonstrates only fair clinical outcomes; moderate degrees of pain, swelling, and stiffness; and, in