1163822 research-article2023 FAOXXX10.1177/24730114231163822Foot & Ankle OrthopaedicsPujol et al Technique Tip Foot & Ankle Orthopaedics ORIF Assisted by Open Subtalar Small 2023, Vol. 8(1) 1­–4 © The Author(s) 2023 DOI: 10.1177/24730114231163822 https://doi.org/10.1177/24730114231163822 Joint Arthroscopy for Intra-articular journals.sagepub.com/home/fao Displaced Calcaneus Fractures Oriol Pujol, MD1 , Andrea Sallent, MD, PhD1, Juan Salom, MD1, Gemma Duarri, MD1, Ignacio Maled, MD1, and Rosa Busquets, MD, PhD1 Keywords: calcaneal fracture, intra-articular fracture, Nanoscope, small joint arthroscopy, surgical aid Introduction tendon injury, or compartment syndrome due to fluid extravasation. Last, it is difficult to insert the traditional Fractures of the calcaneus are severe and complex injuries larger arthroscope into the narrow subtalar joint space with- that result from high-energy injuries. Approximately two- out iatrogenic chondral injury. thirds of them involve the articular surface. Displaced intra- We present a surgical technique for intra-articular dis- articular fractures are generally associated with poor placed calcaneus fractures based on open reduction and health-related quality of life.8 Nonanatomic reduction of the internal fixation (ORIF) assisted by open subtalar arthros- subtalar joint may result in incongruent articular contact, copy using a 1.9-mm arthroscopic device (Nanoscope, which accelerates joint degeneration. In addition, it may Arthrex, Naples, USA). 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 Surgical Technique determinant of outcome.4,8 ORIF for intra-articular displaced calcaneus fractures Subtalar arthroscopy is a useful additional tool to assist should be performed as early as soft tissue swelling has dis- the osteosynthesis procedure.3,11 It aims to provide a real- sipated adequately (positive wrinkle test). Patient is placed time direct and thorough vision of the posterior facet to in the lateral decubitus position. Under thigh tourniquet, the assess the quality of articular reduction and guide reduction lateral extensile approach is performed with gentle soft tis- maneuvers. The narrow space and the irregular and tridi- sue handling. A full-thickness subperiosteal flap is raised mensional shape of the subtalar joint makes congruency dif- and Kirschner wires are placed in the fibula, talar neck, and ficult to evaluate visually or through fluoroscopy. However, some problems related to the traditional subta- 1 Foot and Ankle Unit, Orthopaedic Surgery Department, Vall d’Hebron lar arthroscopy can be encountered.9 First, more equipment University Hospital, Universitat Autònoma de Barcelona, Barcelona, is required with a significant amount of apparatus and con- Spain necting cables, which could burden the operating room. Corresponding Author: Furthermore, the proper use of these devices may be associ- Oriol Pujol, MD, Foot and Ankle Unit, Orthopaedic Surgery ated with a steep learning curve. Third, in closed arthros- Department, Vall d’Hebron University Hospital, Universitat Autònoma copy it may be a higher risk of rare but potentially de Barcelona, Pg. Vall d’Hebron 119-129, Barcelona, 08035, Spain. devastating complications, such as neurovascular injury, Email: oriol.pujol@vallhebron.cat Creative 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). 2 Foot & Ankle Orthopaedics 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. cuboid for retraction. The expanded lateral wall is mobi- lized carefully, and fractures lines are identified. Figure 2. Intraoperative photography showing the arthroscope Then, open reduction maneuvers are performed to obtain placement. The scope is not limited by arthroscopic portals; it is proper calcaneus height, width, and coronal alignment and inserted in the surgical wound and it can be moved through the to achieve a precise anatomic reduction of the posterior joint. facet. When reduction seems to be correct under direct visu- alization, temporary Kirschner wires are placed to maintain Discussion it. Then, articular congruency is checked using open subta- lar small joint arthroscopy (Figure 1). The scope can be held A review of the current literature suggests that the role of by the surgeon or the assistant. The screen is placed 1 m subtalar arthroscopy in the management of intra-articular directly in front of the surgeon, inclined to the surgeon eyes. calcaneus fractures is still evolving. Gavlik et al3 demon- The connecting cable is placed together with the other strated that percutaneous, arthroscopically assisted osteo- cables of the surgical field. The scope is not limited by synthesis allows minimally invasive surgery without risking arthroscopic portals; it is inserted in the surgical wound and inadequate reduction of the subtalar joint in selected moder- it can be moved through the joint (Figure 2). The dimen- ately displaced Sanders type II fractures. Similarly, Law sions of this arthroscope (1.9 mm) and its wide view field et al7 combined arthroscopy and fluoroscopy in percutane- allow to insert the scope deep and smoothly into the narrow ous fixation of simple Sanders type II fractures and showed subtalar joint, obtaining a complete vision of the articular excellent long-term functional outcomes. However, percu- surface. If step-off is detected arthroscopically in the poste- taneous techniques should be carefully indicated in com- rior facet, reduction is repeated subsequently under plex and comminuted fracture patterns because of the arthroscopic vision and assistance (Figure 3). Then, fluo- technical difficulty of reduction.3,7 The minimally invasive roscopy is used to assess calcaneal width and height and sinus tarsi approach has gained popularity because of the calcaneocuboid joint congruity. When reduction is deemed lower risk of soft tissue complications and sural nerve satisfactory, internal fixation is performed using a low-pro- injury. However, it is difficult to restore calcaneal width file lateral calcaneal plate. Simultaneously, small joint through this approach, and articular reduction can be arthroscopy can be used to check that anatomic reduction is restricted by the limited surgical view.9 Therefore, subtalar maintained and to detect joint penetration by screws. After arthroscopy can be especially useful to enhance posterior lavage, the full-thickness flap is closed over a deep drain. facet reduction when using a sinus tarsi approach.10 Splint immobilization is maintained until soft tissue is Rammelt et al11 used open subtalar arthroscopy to evalu- not compromised and sutures can be removed, typically at ate the congruency of the posterior facet after seemingly 3-4 weeks. Then, patients are converted into a rigid ankle exact open reduction as judged visually and fluoroscopi- brace. Ankle and subtalar range of motion exercises are cally. They reported that minor steps may be overlooked begun early. However, weightbearing is not initiated until even with the time-consuming Brodén views in about one- 10-12 weeks postoperatively. quarter of all cases because of the posterior facet irregular Pujol et al 3 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 Disadvantages Easy to use and intuitive It should be used in conjunction with fluoroscopy Avoid an increased equipment Increase surgical time Ideal to thoroughly explore the narrow subtalar joint Increase cost Assist 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. shape. Park and Yoon10 stated that a combined approach The handpiece tube is 9.5 cm long, semirigid, and has a using fluoroscopy and open arthroscopy showed better 1.9-mm outer diameter. It carries the detection system at its reduction on CT than fluoroscopy alone. Advantages of distal end (chip-on-tip technology), with a pixel number of open subtalar arthroscopy are that the arthroscope is not 400 × 400. The scope direction of view is 0°, with a 120° restricted to the standard portals and that it does not carry field of view. The dimensions of this arthroscope and its the risk of neurovascular or tendon damage. wide view field allow to insert the scope deep and smoothly The use of this novel 1.9-mm arthroscope may overtake into the narrow subtalar joint, obtaining a thorough vision some of the limitations encountered in the traditional subta- without iatrogenic chondral injury. lar arthroscopy (Table 1). This system consists of a unique The system comes with tailored arthroscopic instru- handpiece device and a tabletlike screen, requiring just 1 ments for interventional purposes. They may help to connecting cable (Figure 1). An LED light source, an illu- assist during reduction maneuvers (Figure 3) and also to mination system, and a detection system are all included in remove small fragments lodged in the medial portion of the handpiece.12 Therefore, it avoids the increased equip- the subtalar joint that are otherwise difficult to reach. ment required in the traditional arthroscopic system. Furthermore, images and videos can be recorded as in Although subtalar arthroscopy may be associated with a conventional arthroscopy. steep learning curve, the simplicity of use of this apparatus Colasanti et al2 treated 31 patients with anterior ankle makes it very intuitive.12 impingement using a small joint arthroscopy technique. This 4 Foot & Ankle Orthopaedics procedure was found to be safe, leading to good clinical ORCID iD results and high patient satisfaction. Labib and Slone6 used Oriol Pujol, MD, https://orcid.org/0000-0003-4760-2730 small joint arthroscopy in patients with ankle fractures to diagnose syndesmotic injuries or small chondral lesions, and References to verify joint reduction. Alvarez et al1 used this tool to extract 1. Alvarez PM, Gallagher J, Curatolo C, Martin KD. Low-flow retained intra-articular ballistics in the ankle. Moreover, ankle arthroscopy for gunshot wounds with retained intra- small joint arthroscopy has shown to be useful in smaller articular ballistic. Arthrosc Tech. 2022;11(11):e2013-e2019. joints of the foot. Kaplan et al5 reported a surgical technique 2. Colasanti CA, Mercer NP, Garcia JV, Kerkhoffs GMMJ, performing nanoscopic cheilectomy for hallux rigidus. Kennedy JG. In-office needle arthroscopy for the treatment Despite the evident advantages of the use of small joint of anterior ankle impingement yields high patient satisfac- arthroscopy, it is not without limitations (Table 1). tion with high rates of return to work and sport. Arthroscopy. Fluoroscopy has better roles in the evaluation of the calca- 2022;38(4):1302-1311. neal width and height, determination of the screw length, 3. Gavlik J, Rammelt S, Zwipp H. Percutaneous, arthroscop- and restoration of the calcaneocuboid joint congruity. ically-assisted osteosynthesis of calcaneus fractures. Arch Therefore, in our opinion, intraoperative small joint arthros- Orthop Trauma Surg. 2002;122(8):424-428. copy should be used in conjunction with fluoroscopy. 4. Gavlik JM, Rammelt S, Zwipp H. The use of subtalar arthros- copy in open reduction and internal fixation of intra-articular Furthermore, adding the use of small joint arthroscopy may calcaneal fractures. Injury. 2002;33(1):63-71. increase overall surgical time and cost. 5. Kaplan DJ, Chen JS, Colasanti CA, et al. Needle arthroscopy In conclusion, ORIF assisted by open subtalar small cheilectomy for hallux rigidus in the office setting. Arthrosc joint arthroscopy may be a useful surgical technique for Tech. 2022;11(3):e385-e390. intra-articular displaced calcaneus fractures. This novel 1.9- 6. Labib SA, Slone HS. Office-based needle arthroscopy for the mm arthroscope provides the advantages of the traditional foot and ankle. Tech Foot Ankle Surg. 2015;14(1):9-11. arthroscopy while overtaking some of its limitations. The 7. Law GW, Yeo NEM, Yeo W, Koo K, Chong KW. Subtalar increased equipment is avoided when using this intuitive arthroscopy and fluoroscopy in percutaneous fixation of intra- system. The very small dimensions of this arthroscope articular calcaneal fractures: long-term outcomes. J Orthop makes it ideal to explore the narrow subtalar joint. On the Surg. 2017;25(1):230949901668499. other hand, its use may increase surgical time and cost. 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. Ethical Approval 9. Park CH. Role of subtalar arthroscopy for displaced intra- The study was performed in accordance with the ethical standards articular calcaneal fractures. Clin Podiatr Med Surg. 2019; as laid down in the 1964 Declaration of Helsinki. 36(2):233-249. 10. Park CH, Yoon DH. Role of subtalar arthroscopy in operative Declaration of Conflicting Interests treatment of Sanders type 2 calcaneal fractures using a sinus tarsi approach. Foot Ankle Int. 2018;39(4):443-449. The author(s) declared no potential conflicts of interest with 11. Rammelt S, Gavlik JM, Barthel S, Zwipp H. The value of respect to the research, authorship, and/or publication of this arti- subtalar arthroscopy in the management of intra-articular cal- cle. ICMJE forms for all authors are available online. caneus fractures. Foot Ankle Int. 2002;23(10):906-916. 12. Stornebrink T, Altink JN, Appelt D, Wijdicks CA, Stufkens Funding SAS, Kerkhoffs GMMJ. Two-millimetre diameter opera- The author(s) received no financial support for the research, tive arthroscopy of the ankle is safe and effective. Knee Surg authorship, and/or publication of this article. Sports Traumatol Arthrosc. 2020;28(10):3080-3086.