Preface

Abstract

Fractures of the foot present unique challenges for fixation because of the thin soft-tissue envelope, the need to support weight bearing, and possible complicating deformity. Predisposing deformities that may require concurrent correction include cavovarus, metatarsus adductus, and rocker bottom Charcot deformities. Inadequate fixation may lead to the development of secondary deformity and arthritis such as in talar neck and calcaneus fractures. The newer limited-incision techniques for calcaneal fractures seek to decrease problems with wound healing, peroneal tendon injury, and postoperative stiffness of the subtalar joint. Although the percutaneous techniques depend heavily on appropriate patient positioning, reduction maneuvers, and imaging to allow anatomic fracture reduction, a minimally invasive sinus tarsi incision is also presented to allow direct visualization of the posterior facet and its extension allowing direct visualization of the calcaneocuboid joint. The importance of preoperative work-up and planning to understand the fracture pattern and tips to obtain and maintain reduction are discussed in great detail. Although limited incision techniques may decrease complications of the standard extensile incision without compromising outcomes, there is a significant learning curve that requires patience, time, and willingness to convert to a more extensile approach if needed. The 2-incision approach to talar neck fractures takes into account both the delicate blood supply and the tendency to fail to achieve proper alignment and rotation when a 1-incision technique is attempted. Although avascular necrosis is the most feared outcome of talar neck fractures and surgery, posttraumatic subtalar arthritis is commonly seen and is likely associated with damage to the subtalar cartilage at the time of injury and inadequate reduction of any of the 3 subtalar facets. The presence of comminution of the medial wall of the talar neck makes it very difficult to anatomically reduce the fractures unless the less-comminuted tension side of the fracture is directly visualized with a lateral incision. Regardless, any incision balances visualization with a risk to the vascular supply, and the incision recommended in this paper preserves both the deltoid and the posterior tubercle branches of the posterior tibial artery. The development of an intramedullary device to correct and support midfoot collapse represents an important advancement in Charcot fracture deformity reconstruction. Intramedullary placement realigns the medial column reconstructing the arch, and is both load bearing and load sharing. However, careful joint preparation of each joint is required along with additional fixation to prevent rotation/micromotion and to promote bony fusion. As this device is fairly new, outcome studies are pending; however, the ability to correct and hopefully maintain the medial and lateral columns makes this new device and technique a potentially powerful new tool in fracture fixation for Charcot and crush-type injuries. The 2 contributions regarding operative fixation of metatarsal fractures stress the importance of not only treating the fractures, which can be challenging in itself, but also addressing potential structural deformities associated with the injury. A background of cavovarus and metatarsus adductus is often overlooked when treating these fractures, and likely contribute to failure of fixation, delayed or nonunions, and recurrence of the fracture. The thorough literature review on fifth metatarsal fractures is an excellent summarization of techniques and outcomes and a thorough guide to the varied operative techniques. The rationale for the location of screw insertion, the size and type of screw, and the depth of penetration are covered, along with indications for when to bone graft and/or perform corrective osteotomies and muscular releases. Corrective osteotomies for fifth metatarsal fractures associated with cavovarus typically involve dorsiflexion first metatarsal osteotomies in forefoot-driven heel varus, lateral calcaneal closing wedge osteotomies, and/or lateral calcaneal shift osteotomies to realign the hindfoot and the pull of the Achilles tendon for more rigid hindfoot-driven heel varus. Distal dorsiflexion osteotomies of the fifth metatarsal may also be useful in unloading the fracture site to allow healing. For metatarsus adductus, the associated deformity can be addressed through metatarsal closing wedge osteotomies or more involved midfoot closing wedge osteotomies. This volume has attempted to address more controversial foot fractures, because of the difficultly with soft tissues, reduction, and poor outcomes, by soliciting contributions from authors making advances in these areas. We hope you find this collection useful in terms of operative techniques for fixation of these fractures along with correction or prevention of deformity, maximizing patient outcomes in the face of these challenging issues.