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Minimal-invasive Osteosynthese von Kalkaneusfrakturen

Minimally invasive fixation of calcaneal fractures

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Zusammenfassung

Operationsziel

Anatomische Reposition dislozierter Kalkaneusfrakturen unter minimaler Traumatisierung der Weichteile.

Indikationen

Extraartikuläre und ausgewählte intraartikuläre Kalkaneusfrakturen (einfaches Frakturmuster: Typ Sanders II, kritische Weichteilverhältnisse, Kontraindikationen zur offenen Reposition), temporäre Stabilisierung bei Komplexverletzungen oder Polytrauma.

Kontraindikationen

Unmöglichkeit der perkutanen Reposition und Retention.

Operationstechnik

Grobreposition der Hauptfragmente mittels einer perkutan in das Tuberfragment eingebrachten Schanz-Schraube. Feinreposition durch Manipulation der Fragmente mittel Kirschner-Drähten, Steinmann-Nägeln, Raspatorium oder Elevatorium über Stichinzisionen. Arthroskopische Kontrolle der Gelenkreposition bei dislozierten intraartikulären Frakturen. Osteosynthese mittels perkutan eingebrachten Schrauben.

Weiterbehandlung

Bewegungsübungen des oberen und unteren Sprunggelenks ab dem 1. postoperativen Tag, Mobilisation unter Teilbelastung des betroffenen Beins mit 20 kg ab dem 2. postoperativen Tag für 6 bis 8 Wochen. Nach Abklingen des postoperativen Ödems werden die eigenen Schuhe getragen.

Ergebnisse

Von 1998 bis 2008 wurde bei 68 Patienten mit dislozierter Kalkaneusfraktur eine definitive perkutane Osteosynthese durchgeführt. Bei 37 Patienten mit intraartikulärer Fraktur vom Typ Sanders IIA und IIB wurde die anatomische Gelenkreposition mittels subtalarer Arthroskopie verifiziert. Es wurden keine weichteilbedingten postoperativen Komplikationen gesehen. Fünfunddreißig Patienten konnten mindestens 2 Jahre, durchschnittlich 5 Jahre nach der Operation, nachuntersucht werden. Subjektiv waren 33 von 35 Patienten mit dem Operationsergebnis zufrieden. Der mittlere AOFAS-Score betrug zum Nachuntersuchungszeitpunkt 90,7 Punkte (64–100 Punkte). Die perkutane Schraubenosteosynthese ist mit einer minimalen Weichteiltraumatisierung und Komplikationsrate verbunden. Sie erlaubt eine frühere Rehabilitation und führt bei sorgfältiger Patientenselektion zu exzellenten Ergebnissen. Bei intraartikulären Frakturen muss die exakte Reposition der Gelenkfläche intraoperativ überprüft werden.

Abstract

Objective

Anatomic reduction of displaced calcaneal fractures with minimal soft tissue alteration.

Indications

Extra-articular and selected intra-articular calcaneal fractures (simple fracture pattern: Sanders type II, critical soft tissue conditions, contraindications to open reduction), temporary stabilization of complex injuries or polytraumatized patients.

Contraindications

Impossible percutaneous reduction and fixation.

Surgical technique

Gross reduction of the main fragments is achieved with a Schanz screw introduced percutaneously into the tuberosity fragment. Fine reduction is obtained through percutaneous manipulation of the fragments wit Kirschner wires, Steinmann pins, sharp and smooth elevators via stab incisions. Anatomic reduction of the subtalar joint is controlled arthroscopically in cases of displaced intra-articular fractures. Fixation is achieved with screws introduced percutaneously.

Postoperative management

Early range of motion exercises of the ankle and subtalar joints are initiated the first postoperative day. Beginning on postoperative day 2, patients are mobilized with partial weight bearing for 6–8 weeks. As soon as the edema has subsided, patients are encouraged to wear their own shoes.

Results

Between 1998 and 2008, 68 patients were treated with definite percutaneous fixation for displaced calcaneal fractures. In 37 patients with intraarticular fractures (Sanders types IIA and IIB), anatomic joint reduction was verified with subtalar arthroscopy. No soft tissue-related complications were observed. Thirty-five patients were followed for a minimum of 2 years postoperatively, the average was 5 years postoperatively. Subjectively, 33 of 35 patients were satisfied with the clinical outcome. The AOFAS Hindfoot Score averaged 90.7 (range 64–100) at a mean of 5 years after surgery. Percutaneous screw fixation of calcaneal fractures is associated with minimal soft tissue traumatization and low complication rates. It allows early rehabilitation and excellent results with proper patient selection. With intra-articular fractures, proper reduction of the articular surface has to be confirmed intraoperatively.

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  1. Klinik und Poliklinik für Unfall- und Wiederherstellungschirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland

    S. Rammelt, C. Dürr, W. Schneiders & H. Zwipp

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  1. S. Rammelt
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  2. C. Dürr
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  3. W. Schneiders
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  4. H. Zwipp
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Correspondence to S. Rammelt.

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Rammelt, S., Dürr, C., Schneiders, W. et al. Minimal-invasive Osteosynthese von Kalkaneusfrakturen. Oper Orthop Traumatol 24, 383–395 (2012). https://doi.org/10.1007/s00064-012-0172-9

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