Technical tip - Using peroperative distraction in calcaneal fracture surgery after correction of hindfoot varus

Calcaneus fracture surgery requires a well thought-out but pragmatic approach. The general fracture dislocation pattern involves shortening and varus deformation. The sinus tarsi approach (STA), which is performed in the lateral decubitus position, has become a more popular option due to its decreased soft tissue complication rate, while retaining the ability to perform anatomic reduction and fixation of most calcaneus fractures. As the STA technique requires indirect reduction, an assistive devise can be used to facilitate the reduction.

The STA is performed in the lateral decubitus position by performing the following five consecutive steps: first, the medial joint surface (sustentaculum tali) is reduced and temporarily stabilized by inserting a medial plantar 1.6 mm K-wire. Second, the 5.0 mm Schanz pin is inserted perpendicularly into the infero-lateral tuberosity, and the calcaneus tuber length and varus are corrected while restoring medial wall congruency. The previously placed two 1.6 mm k-wires are advanced from the plantar medial tuber into the sustentaculum fragment. Third, the mini distractor is mounted after inserting 3.0 mm Schanz pins into the base of the neck of the talus, making sure the tip engages the far cortex. Fourth, distraction is applied using the mini-distractor to further restore height and length of the tuber and body of the calcaneus and to clear space in the posterior facet which aides in the reduction of the lateral joint fragment. Lastly, internal fixation is applied by means of a posterior facet/tuber extension type of lateral anatomical plate and independent angled axial screws.

This current technical tip shows how to correct varus first and then uses the same Schanz pin for the use of a mini-distractor on the lateral side of the hindfoot.The technique described places the patient in a lateral decubitus position without the need for medial access to the hindfoot. Reduction and fixation of intra-articular calcaneal fractures safely can be performed with limited lateral incisions.