Rev. bras. ortop. vol.52 número1

r e v b r a s o r t o p . 2017;52(1):119–122

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Technical

Note

Resection

osteotomy

for

calcaneus

flattening

after

micro-surgical

flap:

technical

note

夽

Mário

Yoshihide

Kuwae,

Edegmar

Nunes

Costa,

Ricardo

Pereira

da

Silva,

Alexandre

Daher

Albieri,

Frederico

Barra

de

Moraes

UniversidadeFederaldeGoiás(UFG),FaculdadedeMedicina,Goiânia,GO,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received21February2016 Accepted18March2016

Availableonline1December2016

Keywords: Fractures,open Calcaneus

Orthopedicprocedures/methods Surgicalflaps

Osteotomy/methods

a

b

s

t

r

a

c

t

Anopenfractureofthecalcaneuswithlossofsubstanceisachallenginginjuryandrequires specializedcare,involveshighcosts,anddemandsattentiondespiteitslowerincidence.The maincomplicationsareosteomyelitis,pressureulcers,andfistulas,aswellaspain condi-tionsinthelateral,medial,andplantarregions.Thisisduetothewidelossoftissueandthe changeinanatomicalconformationofthecalcaneusinsomecases.However,incasesof flat-teningofthecalcaneusbone,thesecomplicationsmaybepreventedortreatedsuccessfully. Thistechnicalnotedescribestheresectionosteotomytechniqueforcalcaneusflatteningto preventandtreatcomplicationsaftermicro-surgicalflapincasesofopenfractureorlossof substance.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Osteotomia

de

ressecc¸ão

para

aplainamento

do

calcâneo

após

retalho

microcirúrgico:

nota

técnica

Palavras-chave: Fraturasexpostas Calcâneo Procedimentos ortopédicos/métodos Retalhoscirúrgicos Osteotomia/métodos

r

e

s

u

m

o

Afraturaexpostadocalcâneocomperdadesubstânciaéumalesãodesafiadora,demanda cuidados especializados,envolve elevadoscustoseexigeatenc¸ão,apesardesua menor incidência.Asprincipaiscomplicac¸õessãoosteomielite,úlcerasdepressão,fistulas,além dequadrosálgicosnasregiõeslateral,medialeplantar.Essarelac¸ãosedeveàgrandeperda detecidoeàmudanc¸adaconformac¸ãoanatômicadocalcâneoemalgunscasos.Porém, quandoocorreumamodelac¸ãodoformatoósseodocalcâneocomseuaplainamento,essas

夽

StudyconductedattheUniversidadeFederaldeGoiás,FaculdadedeMedicina,HospitaldasClínicas,DepartamentodeOrtopediae Traumatologia,Goiânia,GO,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](F.B.Moraes). http://dx.doi.org/10.1016/j.rboe.2016.11.003

120

complicac¸õespodemserprevenidasoutratadascomsucesso.Oobjetivodestanotatécnicaé descreveratécnicadeosteotomiaderessecc¸ãoparaaplainamentodocalcâneonaprevenc¸ão enotratamentodecomplicac¸õesapósretalhomicrocirúrgicoemcasosdefraturaexposta ouperdadesubstância.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Open fractures of the calcaneus classified as Gustilo and AndersontypeIII1–4_{areassociatedwithshort-andlong-term}

complications.Themaincomplicationsare infections,pain andfistulasorpressureulcersinthetopographyofthelower calcanealtuberosity,evenaftermyocutaneouscoveringwith vascularizedflaps,whichcanbeobservedinuptoone-third ofcases.5–11

Thisisduetotheextensivetissuelossandtochangesin theshapeofthecalcaneusinsomecases.However,incases offlatteningofthecalcaneusbone,thesecomplicationsmay besuccessfullypreventedortreated.

The purpose of this note is to describe a resection osteotomytechniqueforcalcaneusflattening,aimingto pre-ventandtreatcomplicationsaftermicrosurgicalflapincases ofopenfractureortissueloss.

Fig.1–(A)Complicationofcalcanealflapwithplantarulcerandfistulaand(B)debridementofdevitalizedtissueandlocal

preparation.

Fig.2–Lateralradiographsofthecalcaneus.(A)Preoperative,withnoevidenceofosteomyelitisandareasofoverpressure

and(B)postoperative,highlightingtheresectionoftheposteroinferiorcalcanealtuberosity,correctingthedeformities.

Technical

note

Thestepsoftheproposedsurgeryare:

(1) Resection ofulcers and fistulasinthe calcaneal region undertheexistingmicrosurgicalflap;orpreparationofthe areafortheflapthatwillbemade(Fig.1);

(2) Resectionosteotomyforcalcaneusflatteninginthe pos-teroinferiortuberosity,avoidingareasofoverpressureon theoldorthenewflap(Fig.2);

(3) Coveragewithamicrosurgicalflap(Fig.3).

Discussion

rev bras ortop.2017;52(1):119–122

121

Fig.3–Post-operativeaspectofthelatissimusdorsi

microsurgicalflap.

anddemandattention,despitetheirlowincidence.Themain complicationsareosteomyelitis,pressureulcersandfistulas, aswellaspainconditionsinthelateral,medial,andplantar regions.5–11

Fig.6–Lateralradiographofthecalcaneus,withno

evidenceofosteomyelitisandnaturalflatteningof

posteroinferiorcalcanealtuberosity.

This new technique was designed after following-up a teenagepatient(Fig.4)whohadhadacalcanealinjury,healed bysecondintention andthendevelopedulcersandfistulas duetothepresenceofincreasedpressurepoints.Thelesion wasresectedandamicrosurgicalflapofthelatissimusdorsi wasmadeforbettercoverageofthearea(Fig.5),butthe cal-caneuswasleftunapproached.

After approximately ten years, the patient suffered an ankle sprain duringa soccer game;when the ankle radio-graphswereassessed(Fig.6),anaturalflatteningoftheplantar portionofthecalcaneuswasobserved,withoutcomplications suchasulcers,fistulas,orpain(Fig.7).

Fig.4–(A)Preoperativeclinicalaspectofapatientwithulcerandactivefistulainpressureareasinthecalcanealregionand

(B)intraoperativeimageoflesionresectionandmicrosurgicalflaptransplantation.

122

Fig.7–Clinicalaspectofthemicrosurgicalflapandgraftonthecalcaneus(AandB)aftertenyears,withoutthepresenceof

ulcers,fistulae,orregionalpain.

Final

considerations

The resection osteotomy technique for flattening the cal-caneus can be used for the prevention or treatment of complicationsafteramicrosurgicalflapintheregion. Clini-calandsurgicalstudieswithalargernumberofcasesshould beperformedforbetterevaluationofthetechnique.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1. GustiloRB,MendozaRM,WilliamsDN.Problemsinthe managementoftypeIII(severe)openfractures:anew classificationoftypeIIIopenfractures.JTrauma. 1984;24(8):742–6.

2. AcelloAN,WallaceGF,PachudaNM.Treatmentofopen fracturesofthefootandankle:apreliminaryreport.JFoot AnkleSurg.1995;34(4):329–46.

3. GustiloRB.Currentconceptsinthemanagementofopen fractures.InstrCourseLect.1987;36:359–66.

4.GustiloRB,AndersonJT.Preventionofinfectioninthe treatmentofonethousandandtwenty-fiveopenfracturesof longbones:retrospectiveandprospectiveanalyses.JBone JointSurgAm.1976;58(4):453–8.

5.SiebertCH,HansenM,WolterD.Follow-upevaluationofopen intra-articularfracturesofthecalcaneus.ArchOrthop TraumaSurg.1998;117(8):442–7.

6.HeierKA,InfanteAF,WallingAK,SandersRW.Openfractures ofthecalcaneus:soft-tissueinjurydeterminesoutcome.J BoneJointSurgAm.2003;85-A(12):2276–82.

7.AldridgeJM3rd,EasleyM,NunleyJA.Opencalcaneal fractures:resultsofoperativetreatment.JOrthopTrauma. 2004;18(1):7–11.

8.BerryGK,StevensDG,KrederHJ,McKeeM,SchemitschE, StephenDJ.Openfracturesofthecalcaneus:areviewof treatmentandoutcome.JOrthopTrauma.2004;18(4): 202–6.

9.BenirschkeSK,KramerPA.Woundhealingcomplicationsin closedandopencalcanealfractures.JOrthopTrauma. 2004;18(1):1–6.

10.AbidiNA,DhawanS,GruenGS,VogtMT,ContiSF.

Wound-healingriskfactorsafteropenreductionandinternal fixationofcalcanealfractures.FootAnkleInt.

1998;19(12):856–61.