SLR - August 2013 - Jeff Holmes
Reference: Alex J. Kline, Robert B. Anderson, W. Hodges Davis, Carroll P. Jones and Bruce E. Cohen Foot Ankle Int 2013 34: 773 originally published online 4 March 2013
Scientific Literature Review
Reviewed by: Jeff Holmes, DPM
Residency Program: INOVA Fairfax
Podiatric Relevance: Although calcaneal fractures are very common following high-energy trauma, their optimal management remains somewhat controversial. There have been many articles to date debating the treatment for calcaneal fractures, especially those of Sanders II or III. Over the past 20 years, the use of a lateral extensile approach has been the widely accepted surgical procedure in correcting these types of fractures. Over the recent years, however, there seems to be a variety of different types of minimally invasive techniques described due to the high incidence of wound complication with the lateral extensile approach. This article covers one of the biggest studies within podiatric literature comparing the results of a lateral extensile approach to those of a minimally invasive sinus tarsi approach. The classic article of Buckley was one of the first to compare a more minimal approach for the treatment of calcaneal fractures to an extensile surgical approach. This is another type of classic article that provides evidence that an extensile open approach may not always be the procedure of choice.
Methods: Patients included within this retrospective study were those treated for intra-articular calcaneal fractures between October 2005 to December 2008. A total of 112 patients were found that met a criteria consisting of: Sanders type II or III, closed fractures, fractures that underwent operative management via an extensile lateral or minimally invasive sinus tarsi approach, and a minimum of six months of clinical follow-up. Seventy-nine patients were treated with an extensile lateral approach and 33 via a minimally invasive approach. Results were thoroughly reviewed on all 112 fractures, specifically wound healing complications and the need for further surgeries. All patients were asked to return for a research visit. The visit included radiography, clinical exam, and quality of life questionnaires using the SF-36, FFI, and VAS scale. Forty-seven patients elected to participate in this research visit; 31 extensile and 16 minimally invasive were included.
Results: The two groups were comparable with regard to demographics (age, follow-up, male to female ratio, tobacco use, diabetes, and workers’ compensation status). In the extensile group, 53 percent of fractures were Sanders II and 47 percent were Sanders III, whereas in the minimally invasive group 61 percent were Sanders II and 39 percent were Sanders III. The overall wound complication rate was 29 percent in the extensile group (9 percent required operative intervention) versus 6 percent in the minimally invasive group (P = .005) (none required operative intervention). Overall, 20 percent of the extensile group required a secondary surgery within the study period versus 2 percent in the minimally invasive group (P = .007). In the group of patients who returned for research visits, the average FFI total score was 31 in the extensile group versus 22 in the minimally invasive group (P = .21). The average VAS pain score with activity was 36 in the extensile group versus 31 in the minimally invasive group (P = .48). Overall, 84 percent of patients in the extensile group were satisfied with their result versus 94 percent in the minimally invasive group (P = .32). Both groups had 100 percent union rates, and no differences were noted in the final postoperative Bohler’s angle and angle of Gissane.
Conclusions: Clinical results were similar between calcaneal fractures treated with an extensile approach and those treated with a minimally invasive approach. However, the minimally invasive approach had a significantly lower incidence of wound complications and secondary surgeries. The minimally invasive approach was a valuable method for the treatment of intra-articular calcaneal fractures, with low complication rates and results comparable to those treated with an extensile approach.