Busquets, Rosa

Duarri, Gemma

Maled, Ignacio

Pujol, Oriol

Sallent, Andrea

Salom, Juan

Universitat Autònoma de Barcelona

English

Diposit Digital de Documents de la UAB

https://doi.org/10.1177/24730114231163822Foot & Ankle Orthopaedics2023, Vol. 8(1) 1 –4© The Author(s) 2023DOI: 10.1 77/24730114231 638journals.sagepub.com/home/faoCreative Commons Non Commercial CC BY-NC:  This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction  and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages  (https://us.sagepub.com/en-us/nam/open-access-at-sage).Technique TipIntroductionFractures of the calcaneus are severe and complex injuries that result from high-energy injuries. Approximately two-thirds of them involve the articular surface. Displaced intra-articular fractures are generally associated with poor health-related quality of life.8 Nonanatomic reduction of the subtalar joint may result in incongruent articular contact, which accelerates joint degeneration. In addition, it may restrict the inversion/eversion range of motion, leading to difficulty in normal gait. Therefore, anatomic reduction of the posterior facet of the calcaneus is considered a major determinant of outcome.4,8Subtalar arthroscopy is a useful additional tool to assist the osteosynthesis procedure.3,11 It aims to provide a real-time direct and thorough vision of the posterior facet to assess the quality of articular reduction and guide reduction maneuvers. The narrow space and the irregular and tridi-mensional shape of the subtalar joint makes congruency dif-ficult to evaluate visually or through fluoroscopy.However, some problems related to the traditional subta-lar arthroscopy can be encountered.9 First, more equipment is required with a significant amount of apparatus and con-necting cables, which could burden the operating room. Furthermore, the proper use of these devices may be associ-ated with a steep learning curve. Third, in closed arthros-copy it may be a higher risk of rare but potentially devastating complications, such as neurovascular injury, tendon injury, or compartment syndrome due to fluid extravasation. Last, it is difficult to insert the traditional larger arthroscope into the narrow subtalar joint space with-out iatrogenic chondral injury.We present a surgical technique for intra-articular dis-placed calcaneus fractures based on open reduction and internal fixation (ORIF) assisted by open subtalar arthros-copy using a 1.9-mm arthroscopic device (Nanoscope, Arthrex, Naples, USA).Surgical TechniqueORIF for intra-articular displaced calcaneus fractures should be performed as early as soft tissue swelling has dis-sipated adequately (positive wrinkle test). Patient is placed in the lateral decubitus position. Under thigh tourniquet, the lateral extensile approach is performed with gentle soft tis-sue handling. A full-thickness subperiosteal flap is raised and Kirschner wires are placed in the fibula, talar neck, and 1163822 FAOXXX10.1177/24730114231163822Foot & Ankle OrthopaedicsPujol et alresearch-article20231Foot and Ankle Unit, Orthopaedic Surgery Department, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, SpainCorresponding Author:Oriol Pujol, MD, Foot and Ankle Unit, Orthopaedic Surgery Department, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Pg. Vall d’Hebron 119-129, Barcelona, 08035, Spain. Email: oriol.pujol@vallhebron.catORIF Assisted by Open Subtalar Small  Joint Arthroscopy for Intra-articular Displaced Calcaneus FracturesOriol Pujol, MD1 , Andrea Sallent, MD, PhD1, Juan Salom, MD1,  Gemma Duarri, MD1, Ignacio Maled, MD1,  and Rosa Busquets, MD, PhD1Keywords: calcaneal fracture, intra-articular fracture, Nanoscope, small joint arthroscopy, surgical aid2 Foot & Ankle Orthopaedicscuboid for retraction. The expanded lateral wall is mobi-lized carefully, and fractures lines are identified.Then, open reduction maneuvers are performed to obtain proper calcaneus height, width, and coronal alignment and to achieve a precise anatomic reduction of the posterior facet. When reduction seems to be correct under direct visu-alization, temporary Kirschner wires are placed to maintain it. Then, articular congruency is checked using open subta-lar small joint arthroscopy (Figure 1). The scope can be held by the surgeon or the assistant. The screen is placed 1 m directly in front of the surgeon, inclined to the surgeon eyes. The connecting cable is placed together with the other cables of the surgical field. The scope is not limited by arthroscopic portals; it is inserted in the surgical wound and it can be moved through the joint (Figure 2). The dimen-sions of this arthroscope (1.9 mm) and its wide view field allow to insert the scope deep and smoothly into the narrow subtalar joint, obtaining a complete vision of the articular surface. If step-off is detected arthroscopically in the poste-rior facet, reduction is repeated subsequently under arthroscopic vision and assistance (Figure 3). Then, fluo-roscopy is used to assess calcaneal width and height and calcaneocuboid joint congruity. When reduction is deemed satisfactory, internal fixation is performed using a low-pro-file lateral calcaneal plate. Simultaneously, small joint arthroscopy can be used to check that anatomic reduction is maintained and to detect joint penetration by screws. After lavage, the full-thickness flap is closed over a deep drain.Splint immobilization is maintained until soft tissue is not compromised and sutures can be removed, typically at 3-4 weeks. Then, patients are converted into a rigid ankle brace. Ankle and subtalar range of motion exercises are begun early. However, weightbearing is not initiated until 10-12 weeks postoperatively.DiscussionA review of the current literature suggests that the role of subtalar arthroscopy in the management of intra-articular calcaneus fractures is still evolving. Gavlik et al3 demon-strated that percutaneous, arthroscopically assisted osteo-synthesis allows minimally invasive surgery without risking inadequate reduction of the subtalar joint in selected moder-ately displaced Sanders type II fractures. Similarly, Law et al7 combined arthroscopy and fluoroscopy in percutane-ous fixation of simple Sanders type II fractures and showed excellent long-term functional outcomes. However, percu-taneous techniques should be carefully indicated in com-plex and comminuted fracture patterns because of the technical difficulty of reduction.3,7 The minimally invasive sinus tarsi approach has gained popularity because of the lower risk of soft tissue complications and sural nerve injury. However, it is difficult to restore calcaneal width through this approach, and articular reduction can be restricted by the limited surgical view.9 Therefore, subtalar arthroscopy can be especially useful to enhance posterior facet reduction when using a sinus tarsi approach.10Rammelt et al11 used open subtalar arthroscopy to evalu-ate the congruency of the posterior facet after seemingly exact open reduction as judged visually and fluoroscopi-cally. They reported that minor steps may be overlooked even with the time-consuming Brodén views in about one-quarter of all cases because of the posterior facet irregular Figure 1. Intraoperative photography showing the use of open subtalar small joint arthroscopy assisting an ORIF procedure for an intra-articular displaced calcaneus fracture. This novel 1.9-mm arthroscope consists of a unique handpiece device and a tabletlike screen, requiring just 1 connecting cable.Figure 2. Intraoperative photography showing the arthroscope placement. The scope is not limited by arthroscopic portals; it is inserted in the surgical wound and it can be moved through the joint.Pujol et al 3shape. Park and Yoon10 stated that a combined approach using fluoroscopy and open arthroscopy showed better reduction on CT than fluoroscopy alone. Advantages of open subtalar arthroscopy are that the arthroscope is not restricted to the standard portals and that it does not carry the risk of neurovascular or tendon damage.The use of this novel 1.9-mm arthroscope may overtake some of the limitations encountered in the traditional subta-lar arthroscopy (Table 1). This system consists of a unique handpiece device and a tabletlike screen, requiring just 1 connecting cable (Figure 1). An LED light source, an illu-mination system, and a detection system are all included in the handpiece.12 Therefore, it avoids the increased equip-ment required in the traditional arthroscopic system. Although subtalar arthroscopy may be associated with a steep learning curve, the simplicity of use of this apparatus makes it very intuitive.12The handpiece tube is 9.5 cm long, semirigid, and has a 1.9-mm outer diameter. It carries the detection system at its distal end (chip-on-tip technology), with a pixel number of 400 × 400. The scope direction of view is 0°, with a 120° field of view. The dimensions of this arthroscope and its wide view field allow to insert the scope deep and smoothly into the narrow subtalar joint, obtaining a thorough vision without iatrogenic chondral injury.The system comes with tailored arthroscopic instru-ments for interventional purposes. They may help to assist during reduction maneuvers (Figure 3) and also to remove small fragments lodged in the medial portion of the subtalar joint that are otherwise difficult to reach. Furthermore, images and videos can be recorded as in conventional arthroscopy.Colasanti et al2 treated 31 patients with anterior ankle impingement using a small joint arthroscopy technique. This Figure 3. Intraoperative nanoscopic images. (A) Intra-articular displaced calcaneus fracture. (B) Anatomically reduced fracture. The small joint arthroscopy allows to obtain a thorough vision of the subtalar joint to assess the quality of the reduction. Moreover, it can assist during reduction maneuvers.Table 1. List of Advantages and Disadvantages of Using Open Subtalar Nanoscopy to Assist ORIF for Intra-articular Displaced Calcaneus Fractures.Advantages DisadvantagesEasy to use and intuitive It should be used in conjunction with fluoroscopyAvoid an increased equipment Increase surgical timeIdeal to thoroughly explore the narrow subtalar joint Increase costAssist during reduction maneuvers  Allow to remove small fragments lodged in the medial portion of the subtalar joint  Detect joint penetration by screws  Avoid complications associated with closed arthroscopy  Reduce the exposure to fluoroscopy  Abbreviation: ORIF, open reduction internal fixation.4 Foot & Ankle Orthopaedicsprocedure was found to be safe, leading to good clinical results and high patient satisfaction. Labib and Slone6 used small joint arthroscopy in patients with ankle fractures to diagnose syndesmotic injuries or small chondral lesions, and to verify joint reduction. Alvarez et al1 used this tool to extract retained intra-articular ballistics in the ankle. Moreover, small joint arthroscopy has shown to be useful in smaller joints of the foot. Kaplan et al5 reported a surgical technique performing nanoscopic cheilectomy for hallux rigidus.Despite the evident advantages of the use of small joint arthroscopy, it is not without limitations (Table 1). Fluoroscopy has better roles in the evaluation of the calca-neal width and height, determination of the screw length, and restoration of the calcaneocuboid joint congruity. Therefore, in our opinion, intraoperative small joint arthros-copy should be used in conjunction with fluoroscopy. Furthermore, adding the use of small joint arthroscopy may increase overall surgical time and cost.In conclusion, ORIF assisted by open subtalar small joint arthroscopy may be a useful surgical technique for intra-articular displaced calcaneus fractures. This novel 1.9-mm arthroscope provides the advantages of the traditional arthroscopy while overtaking some of its limitations. The increased equipment is avoided when using this intuitive system. The very small dimensions of this arthroscope makes it ideal to explore the narrow subtalar joint. On the other hand, its use may increase surgical time and cost.Ethical ApprovalThe study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki.Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this arti-cle. ICMJE forms for all authors are available online.FundingThe author(s) received no financial support for the research, authorship, and/or publication of this article.ORCID iDOriol Pujol, MD,  https://orcid.org/0000-0003-4760-2730References 1. Alvarez PM, Gallagher J, Curatolo C,  Martin KD. Low-flow ankle arthroscopy for gunshot wounds with retained intra-articular ballistic. Arthrosc Tech. 2022;11(11):e2013-e2019. 2. Colasanti CA, Mercer NP, Garcia JV, Kerkhoffs GMMJ, Kennedy JG. In-office needle arthroscopy for the treatment of anterior ankle impingement yields high patient satisfac-tion with high rates of return to work and sport. Arthroscopy. 2022;38(4):1302-1311. 3. Gavlik J, Rammelt S,  Zwipp H. Percutaneous, arthroscop-ically-assisted osteosynthesis of calcaneus fractures. Arch Orthop Trauma Surg. 2002;122(8):424-428. 4. Gavlik JM, Rammelt S,  Zwipp H. The use of subtalar arthros-copy in open reduction and internal fixation of intra-articular calcaneal fractures. Injury. 2002;33(1):63-71. 5. Kaplan DJ, Chen JS, Colasanti CA, et al. Needle arthroscopy cheilectomy for hallux rigidus in the office setting. Arthrosc Tech. 2022;11(3):e385-e390. 6. Labib SA,  Slone HS. Office-based needle arthroscopy for the foot and ankle. Tech Foot Ankle Surg. 2015;14(1):9-11. 7. Law GW, Yeo NEM, Yeo W, Koo K,  Chong KW. Subtalar arthroscopy and fluoroscopy in percutaneous fixation of intra-articular calcaneal fractures: long-term outcomes. J Orthop Surg. 2017;25(1):230949901668499. 8. Liu GT, Vanpelt MD, Lalli T, Raspovic KM,  Wukich DK. Surgical management of displaced intra-articular calcaneal fractures. Clin Podiatr Med Surg. 2019;36(2):173-184. 9. Park CH. Role of subtalar arthroscopy for displaced intra-articular calcaneal fractures. Clin Podiatr Med Surg. 2019; 36(2):233-249. 10. Park CH,  Yoon DH. Role of subtalar arthroscopy in operative treatment of Sanders type 2 calcaneal fractures using a sinus tarsi approach. Foot Ankle Int. 2018;39(4):443-449. 11. Rammelt S, Gavlik JM, Barthel S,  Zwipp H. The value of subtalar arthroscopy in the management of intra-articular cal-caneus fractures. Foot Ankle Int. 2002;23(10):906-916. 12. Stornebrink T, Altink JN, Appelt D, Wijdicks CA, Stufkens SAS,  Kerkhoffs GMMJ. Two-millimetre diameter opera-tive arthroscopy of the ankle is safe and effective. Knee Surg Sports Traumatol Arthrosc. 2020;28(10):3080-3086.

ORIF Assisted by Open Subtalar Small Joint Arthroscopy for Intra-articular Displaced Calcaneus Fractures

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ORIF Assisted by Open Subtalar Small Joint Arthroscopy for Intra-articular Displaced Calcaneus Fractures

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