Calcaneus Fracture and Posterior Arthroscopic Primary Subtalar Arthrodesis (C-PASTA)

• Published in: JBJS essential surgical techniques 2022-07, Vol.12 (3), p.e21.00057-e21.00057
• Main Authors: Martin, Kevin, Yoder, R. Garrett
• Format: Article
• Language: English
• Subjects: Subspecialty Procedures
• ISSN: 2160-2204; 2160-2204
• DOI: 10.2106/JBJS.ST.21.00057

Complex intra-articular calcaneal fractures often resulted in secondary pain and deformity, requiring subsequent subtalar arthrodesis . The literature suggests that primary subtalar arthrodesis in the acute period has good functional results . The literature also demonstrates that posterior arthroscopic subtalar arthrodesis for chronic arthritis has favorable results . Thus, we propose an approach to treating these difficult intra-articular calcaneal fractures that utilizes a posterior arthroscopic primary subtalar arthrodesis technique-aptly named Calcaneus Fracture and Posterior Arthroscopic Primary Subtalar Arthrodesis (C-PASTA). The procedure begins with the patient in the prone position. The subtalar joint is visualized with a 1.9-mm flexible camera through a standard posterior arthroscopic approach. With the help of the C-arm, position in the subtalar joint space is confirmed. The joint space is debrided with use of a 4-0 shaver and then prepared for arthrodesis arthroscopically with use of an osteotome and a burr. Next, we inject allograft demineralized matrix-based bone putty under direct arthroscopic visualization to fill residual gaps or defects. The arthrodesis is performed under fluoroscopic guidance with use of 2 guidewires followed by 2 to 3 titanium compression screws. The first screw is inserted along the posteromedial calcaneus and into the talar dome medially. The second is placed laterally into the head-neck junction of the talus. The third screw is placed distal to proximal from the plantar anterior process to the talar head. Finally, images are obtained in multiple views to ensure proper screw placement, and the screws are tightened sequentially to ensure equal compression across the joint. Nonoperative treatment of calcaneal fractures includes cast immobilization with non-weight-bearing, although this treatment is typically reserved for nondisplaced, small extra-articular fractures . Operative treatment of calcaneal fractures includes open reduction and internal fixation, which is traditionally performed via a sinus tarsi approach or extensile lateral approach. Primary subtalar arthrodesis has been utilized primarily for Sanders type-IV fractures . Displaced intra-articular calcaneal fractures are associated with alarmingly high rates of posttraumatic arthritis (30% to 70% within 1 year of injury), and surgical outcomes are inversely proportional to the severity of the fracture pattern, with Sanders III and IV having the worst outcome