Percutaneous removal of hardware following open reduction and internal fixation of calcaneus fractures
January 1st, 2003
Emmanuel Stamatis MD
Mark S. Myerson MD
Introduction
Over the past decade open reduction and internal fixation of comminuted calcaneus fractures has been advocated as the treatment of choice for selected patients. The goal of internal fixation is the restoration of the anatomy of the hindfoot including the articular surfaces, in order to maximize function of the hindfoot. Open reduction and internal fixation (ORIF) is however not always successful, and approximately 10% of patients experience postoperative problems including prominent or painful hardware, subtalar arthritis with or without collapse of the subtalar joint, and impingement syndromes. Certainly, routine removal of hardware is unnecessary, and is performed only under specific circumstances. The indications for hardware removal include: painful symptoms specifically related to the hardware such as peroneal tendon irritation; a deep infection occurring six weeks or later following open reduction; and in conjunction with subtalar arthrodesis if the hardware is prominent or interferes with the reconstruction. This article describes a technique for percutaneous removal of the hardware from the calcaneus, utilizing either a two centimeter incision for the plate removal combined with multiple stab incisions for removal of the screws.
Surgical Technique
If an isolated in situ arthrodesis is to be carried out, then a two centimeter incision is performed over the sinus tarsi, and deepened through the subcutaneous tissues. The peroneal tendon sheath and the sural nerve are identified and retracted at the inferior and distal part of the incision respectively. The soft tissues are stripped off the undersurface of the peroneal retinaculum exposing the superior portion of the plate and some of the screws. With adequate and gentle soft tissue retraction the visible screws are removed. The remaining screws which cannot be removed under direct visualization are removed percutaneously utilizing fluoroscopic imaging. Each screw is marked with a needle or a fine k-wire under fluoroscopy and a 3mm skin incision is performed above it. The subcutaneous tissues are blindly spread utilizing a hemostat clamp in order to avoid an inadvertent injury to the sural nerve or its branches. In this manner all screws are gradually removed. Working from dorsal to plantar the plate is elevated off the deep soft tissues utilizing a periosteal elevator, and then grasped with a strong needle-nose plier and removed.
If a distraction bone block subtalar arthrodesis is performed, then 2cm of the vertical part of the incision is utilized. The same vertical incision is used in the presence of wound healing problems-especially at the apex of the flap-or in cases of removal of the implant because of skin irritation. As was described above, and working from posterior to anterior the plate is removed.
Discussion
The most popular incision for exposure during ORIF of calcaneus fractures is an extensile lateral approach, which includes the peroneal tendons and sural nerve in the flap. This technique provides excellent exposure, and is reported to be associated with a lower wound complication rate than with other incisions. We have found however that when the hardware needs to be removed either as an isolated procedure, or in conjunction with a subtalar arthrodesis, the exposure using the original incision can be tedious due to scarring. Furthermore, there are alternate approaches, which may be used for performing the arthrodesis, which either do not necessitate or are contra-indicated using the original extensile incision. The technique described above facilitates relatively easy and safe implant removal from the calcaneus without the risk of wound complications.
A subtalar arthrodesis following ORIF can be performed in situ, or with a distraction bone block graft inserted into the subtalar joint to restore height of the hindfoot. If the anatomy of the hindfoot had been well restored following ORIF, we have found that it is not necessary to use the original extensile incision for exposure. Instead, a short limited incision over the sinus tarsi is sufficient for both implant removal and joint preparation. We have not encountered any wound complications when using this incision, and as noted, it avoids the tedious elevation of the original flap, which may then increase the risk of wound problems. A different scenario is present when a subtalar distraction arthrodesis is performed, since a vertical posterior incision only can be used for exposure. For these cases, the hardware may be removed as described above in conjunction with the arthrodesis. If however the inferior horizontal limb of the incision has to be used, then one should wait for two to three months until the wound is completely healed before proceeding in a staged fashion with the distraction arthrodesis.
This technique of percutaneous hardware removal is versatile, avoids extensive tissue dissection, and since the apex of the initial incision is not elevated, the potential for wound dehiscence is minimized.
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