Fractures of the calcaneus: open reduction and internal fixation from the medial side a 21-year prospective study.

Since 1974, 61 displaced fractures of the calcaneus have been treated by open reduction and internal fixation by a modified medial approach technique. Surgery was performed through a 5-cm incision posterior to the neurovascular bundle. A single threaded pin was passed longitudinally through the tuberosity and into the sustentacular fragment, giving stable fixation. Reduction of the depressed posterior facet fragments was accomplished from the medial side in 77% of cases, occasionally assisted by fluoroscopy. Postoperatively all fractures were immobilized in a cast for 4 weeks. At the end of 4 weeks the pin was removed, and full weight bearing in a walking cast was started and continued for 4 weeks. At 8 weeks after surgery, the walking cast was removed, and the patient began walking in a shoe. These cases were evaluated at a mean follow-up of 4.4 years. There were 49 successful cases (80.3%) and 12 unsuccessful cases (19.7%). A high number of superior results was found in the successful group as shown by the mean score of 94.7 (American Orthopaedic Foot & Ankle Society Scoring System). Time to return to work was a mean of 4.9 months.

The medical approach for calcaneal fractures.

A practical classification of calcaneus fractures based on standard heel roentgenograms and Brodén's views is presented. Diagnosis is made from these roentgenograms, even though many believe that more sophisticated studies are needed. In fact, only the Brodén's and lateral views are needed for diagnosis. What one needs to know is the type of fracture present, whether it is a tongue or joint depression-type fracture, and the width of the fragment. The necessary information is easily determined from these roentgenograms. Once these facts are known, a plan of approach can be made. The medial approach is an indirect method of reduction as one might use for the tibia or femur fracture. Experience has shown that the longitudinal threaded pin is an excellent method of stabilization. It is quick and effective. It has eliminated the need for exposure of the neurovascular bundle. Minimal metal is implanted, and a smaller incision is used. Most common calcaneal fractures can be reduced well from the medial side. A few may need lateral reduction also, but this is simplified if the nonarticular components of the fracture are reduced first by the medial approach technique. The results of the medial approach technique have been much better in the last 12 years. This is attributed to the classification, the knowledgeable interpretation of the roentgenograms, and use of the threaded longitudinal pin for fixation.

Treatment of difficult fractures and nonunions of the humerus and elbow with a modified Küntscher nail.

A series of fourteen difficult fractures and nonunions of the humerus and elbow have been treated over a period of twenty-eight years with a modified Kuntscher Nail. A total of twenty-six operative attempts had been previously made in this group of fourteen patients. One patient had eight failed surgeries prior to treatment. Slots were placed along the spine of the nail for transfixion with screws. In two instances additional modification of the Kuntscher nail was made by attaching a plate to the end of the nail for fixation to the ulna after retrograde insertion into the humerus. One such device was used to fuse the elbow. The other was used to stabilize a low nonunion in which the elbow was already fused. Union was obtained in nine cases with failure in five. Four of the failures united with one additional surgery. The one failed case had a surgical neck fracture which was eventually treated with a Neer prosthesis. The method described may not be superior to other methods; however, it can be successful in obtaining union in difficult elbow and humerus fractures or nonunions resulting from multiple failed prior procedures.

Calcaneus fractures: rationale for the medial approach technique of reduction.

The fractured calcaneus is an enigma to many orthopedic surgeons. Because of this they are often not reduced as well as they might be. The majority of these fractures can be adequately reduced by the medial approach. This approach is based on the fact that a definite pattern of fracture occurs on the medial side of the calcaneus, whereas there is no pattern on the lateral side. If one restores the medial wall of the calcaneus, which is most accurately done from the medial side, the height, length, and much of the width is restored. Strong pressure over the lateral bulge is necessary to completely restore normal width. Generally, the tongue or joint depression-type fragments can be reduced from the medial side. If not, a separate, lateral incision is used to insure their reduction. The neurovascular bundle is no longer dissected out, removing a psychological barrier to the medial approach. A strong recommendation is made to use the longitudinal pin method of fixation. It is simple, and extremely strong. A classification of calcaneus fractures is presented, which can help in preoperative planning for reduction of these fractures.

Reduction of calcaneal fractures by the McReynolds medial approach technique and its experimental basis.

Most calcaneal fractures are of the joint depression type or the tongue type, both of which are amenable to reduction by the medial approach technique. This procedure is based on the principle of restoring the medial wall of the calcaneus, which must be done from the medial side. An accurate reduction produces stability, restores length and height, and partially restores width. The joint depression- or tongue-type fragment is reduced to restore the articular surface of the posterior facet. Many of these fractures can be reduced from the medial side. However, if necessary, a lateral incision should also be made for accurate replacement of these fragments. The final restoration of calcaneal width is accomplished by reducing the lateral bulge of the tuberosity by applying direct pressure over the lateral heel. This deformity, which produces morbidity, must be completely reduced. The medial approach technique offers an opportunity to reduce each of the deformities of the depressed calcaneal fracture. The method is recommended.