SLR - April 2023 - Brandon Selby Blanken, DPM PGY3
Title: Comparison of the Curative Effect of Percutaneous Reduction with Plastic Calcaneal Forceps Combined with Medial External Fixation in the Treatment of Intra-Articular Calcaneal FracturesReference: Wang J, Qin S, Wang T, Liu J, Wang Z. Comparison of the Curative Effect of Percutaneous Reduction with Plastic Calcaneal Forceps Combined with Medial External Fixation in the Treatment of Intra-Articular Calcaneal Fractures. Orthop Surg. 2021 Dec;13(8)
Level of Evidence: Level IV comparative study
Scientific Literature Review
Reviewed By: Brandon Selby Blanken, DPM PGY3
Residency Program: The Eastern Virginia Medical School, Podiatric Medicine and Surgical Residency Program. Norfolk Virginia
Podiatric Relevance: Calcaneal fracture management is a challenge both intra-operatively and post-operatively. Wound complications are the most common difficulties following calcaneal fracture management. Although osseous goals are well-established in regard to calcaneus fracture care, there is no standard for incisional approach. This article details the results of a novel percutaneous minimally invasive approach with external fixation. The authors compared their approach versus the well-established sinus tarsi approach for Sanders II and III fractures.
Methods: The novel percutaneous approach utilizes 6 pins placed with fluoroscopic assistance. The two axial pins fixated within adjacent joints were to stabilize length approximation and varus reduction, while the four lateral pins stabilized height and width. This approach was utilized in 30 patients with Sanders II or III fractures versus 34 in the sinus tarsi approach group. Functional scores including AOFAS, VAS, SF-36 and Maryland foot function were monitored preoperatively and in series up to 2 years postoperatively. X-ray and CT scans were performed on a frequent basis assessing calcaneal shape, Bohler and Glissane angle, and varus angle.
Results: There were significant differences in the following: time to surgery (3.65 days for percutaneous vs. 7.27 sinus tarsi), hospital stay, blood loss (50.62ml vs. 98.83ml), operative time (59.63 minutes vs. 76.27 minutes) and complications (2 vs. 6). With regards to change in calcaneal height, width, and height there were no significant differences between results at any time interval. There were no significant differences between groups regarding Bohler angle, Gissane angle, or Varus angle. At final follow up, there was no difference between groups for the clinical scores (AOFAS, VAS, SF-36, Maryland).
Conclusions: The authors were able to demonstrate that their novel technique had equal clinical and radiologic outcomes compared to the sinus tarsi approach for Sanders II and III fractures. Common complications with standard sinus tarsi and lateral extensile approach include wound complication, neuritis, and lag time between time of injury to time of procedure. This comparative study opens the door for surgeons to utilize an effective technique that reduces the chance of these complications. Overall, the utilization of percutaneous fixation and intra-operative external fixation and fluoroscopy for lower extremity fractures may prove useful. Degree of fracture comminution, soft tissue quality, and medical comorbidity that would convey poor wound healing are less concerning with the percutaneous approach. The foot and ankle surgeon should feel well equipped to treat calcaneal fractures with this approach and expect appropriate outcomes regardless of issues that in the past would delay and/or defer treatment.