Preoplateraldemonstratingjointdepressiontypeoffracturewithdisplacementofatuberosityandextensionintothecalcanealcuboidjoint.The30degreesemi-coronalandaxialCATscansofthefracture.TALUSDISPLACEDPOSTERIORFACETINTACTPOSTERIORFACETSECONDARYFRACTURELINETUBEROSITYANTEROLATERALFRAGMENTTHALAMIC(SUSTENTACULAR)FRAGMENTDISPLACEDPOSTERIORFACETThepatientispositionedcarefullyinthelateraldecubituspositionwithpadsundertheaxillaanddownsideperonealnerve.Thedownlegisplacedforwardagainstandparallelwiththeanterioredgeofthebed.Pillowsareplacedbetweenthelegsandenoughsheetsbehindthedownlegsuchthattheoperativelegliesparallelwiththegroundandatthelevelofthepatient’ship.Thewrinkletest,asdescribedbySanders,involvesdorsiflexingthefootfromaplantar-fixedpositionandlookingfornormalskinturgor,asevidencedbywrinklingoftheskinalongtheareaofthelateralpartofthefoot.ANTERIORACHILLESBORDERINCISIONPERONEALTENDONSFIFTHMETATARSALTheincisionisslightlycurvedandL-shaped,beginningjustanteriortotheAchilles,curvingattheleveloftheskincolorchange,runningparallelwiththesoleofthefootandthencurvingslightlyupanteriorlyatitsdistalextent.FIBULAWiththetourniquetinflated,thecorneroftheincisionisbroughtdirectlydowntobone.ABDUCTORFASCIATowardthedistalextentoftheincisionthefasciaoftheabductorshouldbeidentifiedanddissectionshouldbeperformedsuperficiallytothissoasnottodevascularizethemusclelayer.Inordertodissectdirectlyonthecalcaneusinasubperiostealmanner,significanttensionshouldbedevelopedbyholdingtheheelinvertedwiththethumbandpullingdirectlylaterallyawayfromthefootwithasharpretractorhelddeepintheflap.TENSIONThetensionasdevelopedallowsforeasydissectioninasubperiostealmanner,withaknifethatisheldessentiallyparallelwiththebone.Many#15bladeswillbenecessaryinordertodissectouttheentirecalcaneus.PERONEALTENDONSAftertheflapiscompletelyelevated,theperonealtendonsarevisibleatthedistalextentoftheflap.Caremustbetakennottodamagethesetendonsasthedissectionprogressesdistally.LATERALPROCESSOFTALUSCloseupviewdemonstratingthatwithflapelevationthelateralprocessandposteriorfacetofthetalusisidentified.AK-wireisplacedintothetalarbodyfromthelateralprocessandusedtoretracttheflap.PININFIBULAPININTALUSDISPLACEDPOSTERIORFACETThelateralwallanddisplacedportionoftheposteriorfacetofthecalcaneususremoved.TUBEROSITYINTACTPOSTERIORFACETOFCALCANEUSPOSTERIORFACETTALUSDISPLACEDPOSTERIORFACETAbonehookcanbeusedtopullthetuberositydowntoitsnormalposition;thisreductionisnecessarytoallowforreductionoftheposteriorfacetwithoutstericinterference.TUBEROSITYINTACTPOSTERIORFACETOFCALCANEUSPOSTERIORFACETTALUSDISPLACEDPOSTERIORFACETInthisfigure,theposteriorfacetofthetalusisvisiblewiththeintactmedialportionoftheposteriorfacetofthecalcaneusremaininginitsreducedposition.Thefracturedlateralportionofthefacetisvisibleasitisbeingremoved.K-WIREFREERELEVATORAftercleaningthefragment,theposteriorfacetisreducedanatomicallywiththeaidofaFreerelevatorinpalpatingthereduction,whichissometimesverydifficulttosee.ThisisheldinplacewithaK-wireK-WIREFREERELEVATOROncethereductionisconfirmedunderdirectvisionandfluoroscopy,itisfixedwithcorticallagscrews(nextimage).Thefractureisanatomicallyreducedandvisiblewithforcefulinversionoftheheel.POSTERIORFACETTALUSPOSTERIORFACETREDUCTIONAheadlampcandirectlightagainsttheposteriorfacetofthecalcaneusbyreflectingitofftheposteriorfacetofthetalus.Thelateralx-raydemonstratingK-wireholdingthetuberosityinposition.AlsonoteaK-wireintheareaoftheangleofGissane,holdingtheanterolateralfragmentreduced.Reductionoftheanterolateralfragmentisusuallyobtainedbyforcefulmanipulationwitheitheraballspikeorperiostealelevator.AK-wirecanthenbeplacedintheanterolateralfragmentintotheintactmedialsustentacularfragment(arrow).ANGLEOFGISSANEThelateralwallfragmentsarepiecedbackaswellaspossible,giventhattheyaresometimescomminuted.Lateralradiographandclinicalpictureaftertheanterolateralandanteriorportionofcalcaneushavebeenfixedwithlagscrews,demonstratingreductionofthefacet,theanteriorcalcaneusandthetuberosity.AftertheboneisrepositionedandheldinplacewithK-wires,itisplated.Inthisexample,twomini-fragmentplatesareused.However,manyoptionsareavailablefortheplatefixation.Lateralradiographafterinitialplatefixation.Theclosureisexceedinglyimportantandmustbedoneinseverallayers.Thedeepfasciamustberepairedtotheperiosteumoftheflapwithinterruptedsutures.DRAINThesuturesshouldallbeplacedandtagged,thenclosedfromthedistalextentofthewoundtowardstheapextocontinuallyremovetensionfromtheflapduringtheclosure.TheclosureshouldbeperformedoveraHemovacdrain.IntraoperativeplainradiographsinthelateralandAPplanedemonstratereducedcalcaneus.
